TEXT-BOOK  OF  HYGIENE 


A  COMPREHENSIVE  TREATISE 


Principles  and  Practice  of  Preventive  Medicine 


FROM  AN  AMERICAN  STAND-POINT. 


QKORQE   H.    ROHK,  M.D., 

PROFESSOR  OF  THERAPEUTICS,  HYGIENE,  AND  MENTAL  DISEASES   IN  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS, 

BALTIMORE;  SUPERINTENDENT  OF  THE  MARYLAND  HOSPITAL  FOR  THE  INSANE;  MEMBER  or  THE 

AMERICAN   PUBLIC  HEALTH   ASSOCIATION;    FOREIGN   ASSOCIATE  OF  THE 
FRANCAISE  D'HYGIENB,  KTC. 


THIIP5.D 

THOROUGHLY  REVISED  AND  LARGELY  REWRITTEN,  WITH  MANY 
ILLUSTRATIONS  AND  VALUABLE  TABLES. 


PHILADELPHIA  : 

THE   F.  A.  DAVIS  COMPANY,  PUBLISHERS. 

LONDON : 

F.  J.  REBMAK 

1895. 


COPYRIGHT,  1891, 

BY 

F.  A.  DAVIS. 
COPYRIGHT,  1894, 

BY 

THE  F.  A.  DAVIS  COMPANY. 

[Registered  at  Stationers'  Hall,  London,  Eng.j 


Philadelphia,  Pa.,  U.  S.  A. : 

The  Medical  Bulletin  Printing-House, 
1916  Cherry  Street. 


TO 


HENRY  INGERSOLL  BOWDITCH,  A.M.,  M.D., 


IN   THE   FIELD   OF 


(iii) 


PREFACE  TO  THE  FIRST  EDITION. 


THE  aim  of  the  author  in  writing  this  book  has  been  to 
place  in  the  hands  of  the  American  student,  practitioner, 
and  sanitary  officer,  a  trustworthy  guide  to  the  principles 
and  practice  of  preventive  medicine. 

He  has  endeavored  to  gather  within  its  covers  the  essen- 
tial facts  upon  which  the  art  of  preserving  health  is  based, 
and  to  present  these  to  the  reader  in  clear  and  easily 
understood  language. 

The  author  cannot  flatter  himself  that  much  in  the 
volume  is  new.  He  hopes  nothing  in  it  is  untrue. 


(v) 


PREFACE  TO  THE  THIRD  EDITION. 


IN  this  edition  every  chapter  has  been  subjected  to  a  careful 
revision,  and  the  advances  in  sanitary  science  and  practice  have 
been  incorporated. 

Recent  legislation  in  the  United  States  and  Canada  has 
almost  revolutionized  quarantine  practice.  Surgeon-General 
Walter  Wyman,  and  Dr.  H.  D.  Geddings,  of  the  United 
States  Marine-Hospital  Service,  have,  at  the  request  of  the 
author,  entirely  rewritten  the  chapter  upon  Quarantine,  and 
it  will  be  found  to  represent  fully  the  modern  principles  and 
practice  of  maritime  sanitation. 

Medical  Director  Albert  L.  Gihon,  United  States  Navy,  has 
again  thoroughly  revised  the  chapter  on  Marine  Hygiene. 

With  the  view  of  making  the  book  still  more  useful  to 
teachers,  students,  and  sanitary  officers  than  heretofore,  an  ana- 
lytical set  of  questions  has  been  appended  to  each  chapter,  and 
a  separate  section  has  been  added  on  methods  of  examination 
of  air,  water,  and  food.  For  these  additions  the  author  is 
indebted  to  Professor  Seneca  Egbert,  of  Philadelphia.  Dr. 
Egbert  has  also  carefully  revised  the  chapter  on  Vital  Statistics. 

The  author  desires  to  thank  all  who  have  assisted  him  in 
the  work,  and  especially  the  sanitarians  throughout  the  country 
who  have  been  helpful  in  the  way  of  criticism  and  suggestion. 
He  hopes  that  the  new  edition  will  merit,  as  well  as  receive,  the 
approval  of  all  students  of  Preventive  Medicine. 


BALTIMORE,  MD.,  October,  1894. 


(Vii) 


CONTENTS. 


CHAPTER  I. 

PAGE 
••••••.......  1 

CHAPTER  II. 
WATER,    .        .        .        . 49 

CHAPTER  III. 
FOOD,       ...        .        .        ^ •      ,.       87 

CHAPTER  IV. 

SOIL,  .        .        •     J3H"'  -•  •      '        •        -        .        .      131 

CHAPTER  V. 

REMOVAL  OF  SEWAGE,     .        .        .        .        .        .        .        .        .      147 

CHAPTER  VI. 
CONSTRUCTION  OF  HABITATIONS, 165 

CHAPTER  VII. 
CONSTRUCTION  OF  HOSPITALS, 195 

CHAPTER  VIII. 
SCHOOL  HYGIENE, 207 

CHAPTER  IX. 
INDUSTRIAL  HYGIENE, 223 

CHAPTER  X. 
MILITARY  AND  CAMP  HYGIENE,       .......      249 

CHAPTER  XI. 
MARINE  HYGIENE, 261 

CHAPTER  XII. 

PRISON  HYGIENE, 279 

(ix) 


X  CONTENTS. 

CHAPTER  XIII. 

PAGE 

EXERCISE  ANIT  TRAINING, 285 

CHAPTER  XIV. 
BATHS  AND  BATHING, 293 

CHAPTER  XV. 
CLOTHING,        .        .        . 301 

CHAPTER  XVI. 
DISPOSAL  OF  THE  DEAD, 307 

CHAPTER  XVII. 
THE  GERM  THEORY  OF  DISEASE, 313 

CHAPTER  XVIII. 
CONTAGION  AND  INFECTION, 319 

CHAPTER  XIX. 
HISTORY  OF  EPIDEMIC  DISEASES, 325 

CHAPTER  XX. 

ANTISEPTICS,  DISINFECTANTS,  AND  DEODORANTS,      ....      387 

CHAPTER  XXL 
VITAL  STATISTICS, 401 

CHAPTER  XXII. 

THE  EXAMINATION  OF  AIR,  WATER,  AND  FOOD,    ....      413 

CHAPTER  XXIII. 
QUARANTINE, •    441 

INDEX, 547 


TEXT-BOOK  OF  HYGIENE. 


CHAPTER  L 

AIR. 

EXACT  investigation  into  the  influence  of  the  atmosphere 
upon  health  is  yet  in  its  infancy.  Enough  has  been  learned, 
however,  to  show  that  changes  in  the  composition  of  the  air,  in 
its  density,  its  temperature,  its  humidity,  its  rate  and  direction 
of  motion,  and  possibly  its  electrical  or  magnetic  conditions, 
influence  in  various  ways  the  health  of  the  individual.  It  is 
only  very  recently  that  any  scientific  attempts  have  been  made 
to  trace  the  bearing  of  atmospheric  changes  upon  health.  The 
observations  already  recorded  indicate  that  a  thorough  study  of 
meteorological  phenomena  in  connection  with  the  origin  and 
progress  of  certain  diseases  is  a  promising  field  of  labor  ibr  the 
educated  sanitarian.  The  meteorological  observations  which 
have  been  gathered  by  the  United  States  Signal  Service  during 
the  past  twenty-three  years,  together  with  elaborate  studies 
made  by  the  meteorologists  and  climatologists  of  other  countries, 
already  form  such  a  large  and  tolerably  complete  and  well- 
arranged  body  of  facts,  that  reasonably  accurate  deductions  can 
even  now  be  made.  Heretofore,  in  studying  the  sanitary  rela- 
tions of  the  atmosphere,  both  in  this  country  and  abroad,  the 
attention  of  observers  has  been  riveted  almost  exclusively  upon 
the  changes  in  its  composition  occurring  within  certain  limited 
areas.  It  is,  perhaps,  equally  important  to  study  this  universally 
diffused  and  necessary  condition  of  vital  activity  in  its  broader 
and  more  general  relations.  It  will  be  shown,  in  the  course  of 
the  present  work,  that  the  meteorological  features  of  countries, 

CD 


2  TEXT-BOOK   OF   HYGIENE. 

or  of  seasons,  or  even  the  daily  atmospheric  changes,  exercise  an 
important  influence  upon  life  and  health.  In  order  to  fully 
appreciate  these  relations  it  will  be  necessary  to  first  give  a  brief 
summary  of  the  facts  and  laws  of  meteorology. 

THE   COMPOSITION    AND   PHYSICAL   CONDITIONS   OF  THE  ATMOSPHERE. 

Atmospheric  air  is  a  mixture  of  four-fifths  of  nitrogen  and 
one-fifth  of  oxygen;  more  accurately,  79.00  of  the  former  to 
20.96  of  the  latter.  In  addition,  there  is  constantly  present  a 
modicum  of  carbon  dioxide,  usually  a  little  over  .03  per  cent. 
(3  to  4  parts  in  10,000),  traces  of  ammonia  and  nitric  acid,  and 
a  variable  proportion  of  vapor  of  water. 

These  proportions  are  maintained,  with  but  very  little 
change,  at  different  heights.  At  first  thought,  it  would  seem 
that  carbon  dioxide,  being  much  heavier  than  the  other  con- 
stituents of  air,  would  accumulate  in  the  lower  regions  of  the 
atmosphere,  and  there  cause  an  excess  of  this  poisonous  con- 
stituent, but  in  obedience  to  the  law  of  diffusion  the  interming- 
ling of  the  component  gases  is  perfect,  and  the  proportion  of 
carbon  dioxide  in  the  atmosphere  is  quite  as  great  on  mountain- 
tops  as  in  the  deepest  valleys. 

The  proportion  of  nitrogen  in  atmospheric  air  is  generally 
uniform,  while  that  of  oxygen  varies,  depending  to  a  great  ex- 
tent upon  the.  amount  of  carbon  dioxide  present.  Hence,  an 
increase  in  the  amount  of  the  latter  constituent  is  usually  ac- 
companied by  a  diminution  of  oxygen,  inasmuch  as  the  formation 
of  carbon  dioxide  can  only  take  place  at  the  expense  of  oxygen. 
The  reciprocal  activities  of  animal  and  vegetable  life  are  beauti- 
fully illustrated  by  these  relations  between  the  oxygen  and 
carbon  dioxide  in  the  air.  In  the  processes  of  combustion  and 
oxidation,  oxygen  is  withdrawn  from  the  atmosphere,  and  com- 
bines with  carbon,  forming  carbon  dioxide.  During  vegetable 
growth,  on  the  other  hand,  carbon  dioxide  is  withdrawn  from 
the  air  by  the  leaves  of  plants,  and  decomposed  into  its  elements, 
carbon  and  oxygen.  The  carbon  is  used  in  building  up  the 


COMPOSITION    AND    PHYSICAL   CONDITIONS   OF   ATMOSPHERE.         3 

plant,  while  the  liberated  oxygen  is  restored  to  the  atmosphere. 
The  animal  consumes  oxygen,  and  gives  out  carbon  dioxide; 
the  plant  resolves  this  compound  into  its  constituent  elements, 
and  gives  back  the  oxygen  to  the  air  again. 

Some  recent  experiments  of  Jolly  have  shown  that  on  days 
of  northerly  winds  the  proportion  of  oxygen  is  higher  than  the 
average,  while  under  the  influence  of  the  south  wind  the  propor- 
tion of  oxygen  is  deficient.  The  extremes  in  a  series  of  21 
observations  were  21.01  and  20.53  per  cent.  The  difference, 
.48  per  cent.,  is  too  small  to  have  any  appreciable  influence 
upon  health. 

The  atmosphere  extends  upward  from  the  surface  of  the 
earth  to  an  indefinite  distance.  The  limit  has  been  variously 
placed  at  from  75  kilometres  to  40,000  kilometres.  For  all 
sanitary  purposes  the  former  may  be  taken  as  the  upward  limit 
of  the  atmosphere.  In  obedience,  to  the  law  of  gravity,  this 
mass  of  air  everywhere  presses  directly  downward — toward  the 
earth's  centre — with  a  force  equal  to  its  weight.  If  a  column 
of  this  air  be  balanced  by  a  column  or  mass  of  any  other  matter — 
the  columns  being  of  the  same  diameter — we  have  a  relative 
measure  of  the  weight  of  the  atmosphere.  The  instrument  with 
which  the  weight  or  downward  pressure  of  the  air  is  measured 
is  called  a  barometer.  The  atmosphere,  at  the  sea-level,  presses 
downward  with  a  force  equal  to'  the  pressure  of  a  column  of 
mercury  760  millimetres  high.  Hence,  the  barometric  pressure 
at  sea-level  is  said  to  be  760  millimetres,  or  30  inches.  If  the 
barometer  be  carried  to  the  summit  of  a  mountain  1000  metres 
above  the  level  of  the  sea,  or  taken  to  the  same  altitude  in  a 
balloon,  the  mercury  in  the  barometer- tube  will  fall  about 
90  millimetres.  These  90  millimetres  of  the  mercurial  column 
represent  the  weight  of  1000  metres  of  air  now  below  the 
barometer,  and  consequently  not  measured  or  balanced  by  it.1 

Upon  ascending  from  the  sea-level,  it  is  found  also  that  the 

1  The  figures  here  given  are  not  absolute,  but  merely  approximate.  The  limits  of  this 
work  do  not  allow  a  full  discussion  of  the  meteorological  elements  modifying  the  pressure  of 
the  atmosphere  at  sea-leveL 


4  TEXT-BOOK   OF   HYGIENE. 

air,  being  less  pressed  upon  by  that  which  is  still  above  it, 
becomes  more  rarefied  and  lighter;  its  tension,  as  it  is  termed, 
is  less.  Hence,  for  the  second  1000  metres  of  ascent  above  the 
sea,  the  mercury  will  fall  a  less  distance  in  the  tube,  the  weight 
removed  not  being  so  great  as  in  the  first  1000  metres. 

The  following  table  shows  the  diminution  in  atmospheric 
pressure  for  every  1000  metres  above  sea-level: — 

TABLE  I. 

Height.  Barometric  Pressure. 

Sea-level, 760.0  millimetres. 

1,000  metres, 670.4  " 

2,000  " 591.5  " 

3,000  " 521.0  " 

•     4,000  " 460.3  " 

5,000  " 406.0  " 

6,000  " 358.2  " 

7,000  "  .                          .                 .  316.0  " 

8,000  "  .         .         .         .         .         .  278.8  " 

9,000  " 245.9  " 

10,000  " 216.9  " 

11,000  " 191.1  " 

12,000  " 168.8  " 

15,000  " 115.9  " 

20,000  " 61.9  :; 

Variations  in  temperature  and  humidity  of  the  air  influence 
the  tension  of  the  atmosphere  in  a  marked  degree,  and  affect 
the  height  of  the  barometric  column.  In  fact,  most  of  the 
changes  of  atmospheric  pressure  at  the  surface  of  the  earth  are 
directly  due  to  changes  in  temperature  and  humidity.  Increase 
of  temperature  diminishes  the  density  of  the  air.  Hence,  when 
the  temperature  rises  the  pressure  decreases. 

The  proportion  of  moisture  (aqueous  vapor),  if  increased, 
likewise  causes  a  diminution  in  pressure.  It  is  found,  for  ex- 
ample, that  when  the  amount  of  aqueous  vapor  in  the  air 
increases  the  barometer  falls.  This  is  due  to  the  fact  that  the 
specific  gravity  of  aqueous  vapor  is  less  than  that  of  dry  air, 
being  in  the  proportion  of  .623  to  1.000.  Hence,  as  aqueous 


COMPOSITION    AND    PHYSICAL   CONDITIONS   OF    ATMOSPHERE.        5 

vapor  is  diffused  through  air,  the  latter  becomes  lighter, — or,  in 
other  words,  the  barometric  pressure  diminishes. 

The  warmth  of  the  air  is  primarily  derived  from  the  sun. 
On  a  clear  day  about  one-fourth  of  the  heat  of  the  sun's  rays  is 
given  off  directly  to  the  air  during  the  passage  of  the  heat- 
rays  to  the  earth.  Of  the  remaining  three-fourths,  part  is  re- 
flected from  the  earth,  while  the  larger  portion  is  first  absorbed 
by  the  earth,  and  then  given  off  by  radiation  and  convection  to 
the  superincumbent  air. 

The  air  is  always  warmer  near  the  earth's  surface  on  a  clear, 
sun-shiny  day;  for,  as  soon  as  the  earth  gets  warmer  than  the 
air  immediately  above  it,  the  excess  of  heat  is  given  off  to  the 
latter  by  convection  and  radiation.  On  ascending  from  the 
surface  of  the  earth  the  temperature  decreases,  and  on  the 
summit  of  a  high  mountain  the  air  is  always  colder  than  at 
its  base. 

Professor  Tyndall  has  shown  that  dry  air  absorbs  less 
heat  than  air  which  is  charged  with  vapor.  For  this  reason 
the  sun's  rays  strike  the  earth  with  much  greater  intensity 
on  a  very  dry  than  on  a  moist  day,  while  on  the  latter  a  larger 
proportion  of  the  heat-rays  is  intercepted  before  they  reach 
the  earth. 

Recent  experiments  seem  to  show,  however,  that  the  differ- 
ence in  diathermancy  between  dry  and  humid  air  is  not  so  great 
as  supposed  by  Tyndall.  The  depth  of  the  air-stratum,  through 
which  the  sun's  rays  pass,  is  of  greater  influence  than  the 
humidity. 

Air,  at  different  temperatures,  is  capable  of  absorbing 
different  amounts  of  aqueous  vapor.  Thus,  air  at  a  temperature 
of  4°  will  require  a  much  smaller  amount  of  vapor  to  produce 
saturation  than  air  at  a  temperature  of  30°.  For  this  reason 
air  which  appears  "  damp "  at  the  former  temperature,  both  to 
the  bodily  sensations  and  to  appropriate  instruments,  would  be 
considered  as  "dry"  at  the  latter  temperature,  although  the 
actual  amount  of  vapor  present,  or  absolute  humidity,  is  the 


TEXT-BOOK   OF   HYGIENE. 


same  in  both  cases.1  In  meteorological  observations  for  sanitary 
purposes,  the  relative  humidity  is  the  condition  deserving 
especially  careful  study. 

It  must  be  borne  in  mind  that  the  mere  statement  of  the 
percentage  of  relative  humidity,  without  taking  into  account  the 
temperature  of  the  air,  is  of  little  significance.  A  like  remark 
is  justified  with  regard  to  statements  of  absolute  humidity,  when 
used  to  illustrate  the  apparent  effects  of  atmospheric  moisture 
upon  life  and  health. 

The  following  table  shows  the  absolute  humidity  corre- 
sponding to  the  same  relative  humidity  at  different  tempera- 
tures. It  also  includes  the  total  possible  absolute  humidity 
and  the  difference  between  the  actual  and  possible  humidity 
(deficiency  of  saturation)  at  the  temperatures  given  : — 

TABLE  II. 


Tempera- 
ture °C. 

Relative 
Humidity 
(per  cent.). 

Absolute  Humidity 
(grammes  per 
cubic  metre). 

Greatest  Possible 
Absolute  Humidity. 

Deficiency  of 
Saturation. 

—20 

60 

0.638 

1.064 

0.426 

—10 

60 

1.380 

2.300 

0.920 

0 

60 

2.924 

4.874 

1.950 

+10 
20 

60 
60 

5.623 
10.298 

9.372 
17.164 

3.749 

6.866 

30 

60 

18.083 

30.139 

12.056 

In  forests  the  relative  humidity  is  usually  higher  than  over 
unwooded  districts,  although  the  absolute  humidity  may  be  the 
same,  or,  perhaps,  even  less.  The  evaporation  is  usually  much 
greater  in  the  open  air  than  in  forests.  In  closed  apartments 
the  evaporation  may  be  greater  or  less  than  in  the  open  air,  de- 
pending upon  the  local  conditions  present. 

1  By  "absolute  humidity"  is  meant  the  total  amount  of  vapor  present  in  a  certain  mass 
of  air.  By  the  term  "relative  humidity "  meteorologists  designate  the  proportion  of  vapor 
present  at  certain  temperatures,  compared  with  full  saturation  of  the  air  with  vapor,  which  is 
reckoned  100.  Thus,  air  which  is  saturated,  or  whose  relative  humidity  is  100  at  4°,  would  have 
a  relative  humidity  of  only  24,  if  the  temperature  were  raised  to  27°,  because  in  the  latter  case 
the  capacity  of  the  air  for  aqueous  vapor  is  increased.  Relative  humidity  is  always  designated 
in  percentages  ;  absolute  humidity  in  grammes  per  cubic  metre  or  grains  per  cubic  foot. 


COMPOSITION    AND   PHYSICAL   CONDITIONS   OF   ATMOSPHERE.         7 

The  motion  of  the  air — wind — is  caused  by  differences  in 
pressure ;  the  latter  being  due  to  differences  in  temperature  and 
humidity.  A  mass  of  air  traversing  a  large  body  of  water  absorbs 
vapor,  unless  already  saturated,  and  becomes  moist ;  if  it  pass 
over  a  wide  tract  of  dry  land  it  loses  moisture  and  becomes  dry. 
Therefore  in  the  eastern  portion  of  the  American  continent,  an 
easterly  or  southerly  wind,  which  comes  from  over  large  bodies 
of  water,  and  which  is  usually  warm,  and  thus  capable  of  hold- 
ing a  large  quantity  of  water  in  a  state  of  vapor,  is  always 
moist.  On  the  other  hand,  a  northerly  or  westerly  wind,  com- 
ing over  a  large  extent  of  dry  land,  and  from  a  colder  region,  is 
nearly  always  a  dry  wind.  On  the  Pacific  coast  these  condi- 
tions are  reversed ;  there  a  westerly  wind  is  a  moist  wind,  while 
an  easterly  wind  is  dry.  The  dreaded  easterly  wind  of  England 
is  likewise  a  dry  wind.  It  is  probable  that  the  direction  and 
rate  of  motion  of  air-currents  have  considerable  influence  upon 
the  origin  or  intensification  of  certain  diseases. 

The  electrical  and  magnetic  conditions  of  the  atmosphere 
have  been  as  yet  studied  to  little  advantage.  It  is  only  known 
that  atmospheric  electricity  is,  in  most  cases,  positive,  and  that 
its  intensity  increases  with  condensation  of  vapor.  There  seems 
to  be  no  doubt  that  the  varying  states  of  atmospheric  electricity 
are  closely  connected  with  evaporation  and  condensation.  There 
is  reason  to  believe  that  a  fuller  knowledge  on  these  topics  will 
yield  most  important  results  to  the  student  of  hygiene. 

Ozone  and  antozone,  or  hydrogen  peroxide,  are  usually 
present  in  the  atmosphere  in  varying  proportions.  Careful  and 
extended  observations  have  failed  to  show  any  connection  be- 
tween the  presence  of  these  agents  in  the  atmosphere  and  modi- 
fications of  health.  It  is  probable  that  the  sanitary  importance 
of  ozone  and  of  hydrogen  peroxide  have  been  much  overrated. 
It  is  not  known  that  either  of  these  substances  has  any  other 
function  in  the  atmosphere  than  that  of  an  oxidizing  agent. 

The  sanitarian  should  be  a  practical  meteorologist.  In 
addition  to  a  knowledge  of  the  principles  of  the  science,  he 


8 


TEXT-BOOK   OF    HYGIENE. 


should  possess  the  skill  to  make  accurate  observations  of  me- 
teorological conditions,  and  estimate  their  significance.  But  the 
acquisition  of  an  elaborate  collection  of  instruments,  and  their 
regular  observation,  is  too  expensive  and  time-consuming.  A 

German  physicist,  Lambrecht,  has  de- 
vised an  instrument  which  combines  in 
itself  nearly  all  the  requirements  of  a 
trustworthy  meteorological  instrument 
(Fig.  1).  This  instrument  is  called  a 
polymeter,  and  shows,  on  easily-readable 
scales,  the  temperature,  relative  humid- 
ity, dew-point,  absolute  humidity  in 
grammes  per  cubic  metre,  and  vapor 
tension. 

INFLUENCE   OF   CHANGES   OF  ATMOSPHERIC 
PRESSURE   ON    HEALTH. 

The  effects  of  a  considerable  dimi- 
nution of  pressure  are  familiar  to  every 
one  in  the  "  mountain  sickness  "  which 
attacks  most  persons  on  ascending  high 
mountains.  M.  Bert  has  shown  experi- 
mentally that  similar  effects  can  be 
produced  in  an  air-tight  chamber  by 
diminishing  the  pressure.1  The  symp- 
toms produced  under  a  pressure  equiva- 
lent to  an  altitude  of  from  4000  metres 
to  5000  metres  were  a  feeling  of  heavi- 
ness, nausea,  ocular  fatigue,  rapidity 
of  pulse,  convulsive  trembling  on  slight 
exertion,  and  a  sensation  of  languor 

and  general  indifference  to  the  surroundings  of  the  individual. 
M.  Lortet,  who  has  left  on  record  his  experiences  in  the 

higher  Alps,  says  that  the   symptoms  noticed  on  ascending  to 

1  Popular  Science  Monthly,  v,  p.  379. 


FIG.  1. 
IjAMBRECHT'S  POL.YMETER. 


INFLUENCE   OF   CHANGES   OF   ATMOSPHERIC    PRESSURE.  9 

high  altitudes  are:  Labored  respiration,  increased  rapidity  of 
pulse,  depression  of  temperature  (as  much  as  4°  to  7°  C.).  The 
normal  temperature  was  restored,  however,  after  a  brief  rest.1 
Still  more  severe  symptoms  have  been  noticed  on  ascending  high 
mountains  in  South  America  and  Asia.  Aeronauts  have  lost 
consciousness,  and  in  several  instances  life,  on  rapidly  ascending 
to  great  altitudes.2  According  to  the  observations  of  the 
brothers  Schlagintweit,  distinguished  explorers  of  the  highlands 
of  Asia,  the  effects  of  diminished  pressure  upon  the  human 
organism  are :  "  Headache,  difficulty  of  respiration,  and  affec- 
tions of  the  lungs, — the  latter  even  proceeding  so  far  as  to 
occasion  blood-spitting, — want  of  appetite,  and  even  nausea, 
muscular  weakness,  and  a  general  depression  and  lowness  of 
spirits.  All  these  symptoms,  however,  disappear  in  a  healthy 
man  almost  simultaneously  with  his  return  to  lower  regions." 
A  singular  observation  was  made  by  these  travelers  on  the  effect 
of  motion  of  the  air  upon  the  symptoms  described.  They  say: 
"  The  effects  here  mentioned  were  not  sensibly  increased  by 
cold,  but  the  wind  had  a  most  decided  influence  for  the  worse 
upon  the  feelings When  occupied  with  observa- 
tions, we  took  very  little,  if  any,  bodily  exercise,  sometimes  for 
thirty-six  hours ;  it  would  frequently  occur  nevertheless,  even  in 
heights  not  reaching  17,000  feet  (about  5150  metres),  that  an 
afternoon  or  evening  wind  would  make  us  all  so  sick  as  to  take 
away  every  inclination  for  food.  No  dinner  was  cooked;  the 
next  morning,  when  the  wind  had  subsided,  the  appetite  was 
better. 

"  The  effects  of  diminished  pressure  are  considerably  aggra- 
vated by  fatigue.  It  is  surprising  to  what  degree  it  is  possible 
for  exhaustion  to  supervene  ;  even  the  act  of  speaking  is  felt  to 
be  a  labor,  and  one  gets  as  careless  of  comfort  as  of  danger. 
Many  a  time  our  people — those  who  ought  to  have  served  us  as 
guides — would  throw  themselves  down  upon  the  snow,  declaring 

1  Realencyclopaedie  d.  ges.  Heilk.,  v.,  p.  529. 

2  MM.  Sivelan:!  frocr-Spindli,  two  aeronauts,  lost  their  lives  in  this  manner  during  an 
ascent  from  Paris,  in  April.  1875. 


10  TEXT-BOOK   OF   HYGIENE. 

they   would   rather   die    upon   the   spot   than  proceed  a  step 
farther."1 

These  symptoms  disappear  when  persons  are  exposed  to 
these  conditions  for  a  prolonged  time.  Thus,  in  the  Andes 
there  are  places  4000  metres  above  sea-level  which  are  per- 
manently inhabited ;  and  in  the  Himalayas  there  are  villages 
at  a  height  of  over  5000  metres  constantly  occupied.  In  this 
country,  Pike's  Peak,  4350  metres  above  the  sea,  has  been 
occupied  since  1873  by  observers  of  the  signal  service.  The 
men  seem  to  become  acclimated,  as  it  were,  and  suffer  little  or 
no  inconvenience  from  the  diminished  pressure  after  a  time. 

The  minor  disturbances  of  healthy  function  produced  by 
diminished  pressure  (within  the  limits  of  4000  metres  altitude, 
or  460  millimetres  barometric  pressure)  are  an  increase  in  the 
pulse  and  respiration  rate.  This  is  probably  due  to  the  struggle 
of  the  organism  to  take  up  the  required  quantity  of  oxygen 
which  is  reduced  in  proportion  by  the  rarefaction  of  the  air. 
For  example,  the  proportion  of  oxygen  at  a  pressure  of  460 
millimetres  would  be  equivalent  to  12.6  per  cent,  at  sea-level, 
instead  of  the  normal  20.9  per  cent. 

Paul  Bert  has  shown  by  personal  experiments  in  the 
pneumatic  chamber  that  the  increase  in  pulse  and  respiration 
rate  is  not  due  to  the  merely  mechanical  diminution  of  pressure, 
but  to  the  deficiency  of  oxygen.  Hence  the  physiological  effects 
of  high  altitudes  upon  circulation  and  respiration  are  not  purely 
physical,  due  to  diminished  pressure,  but  vital,  and  depend  upon 
the  change  in  the  chemical  composition  of  the  atmosphere. 
The  simple  dimhmtion  of  oxygen  without  reduction  of  pressure 
will  produce  similar  though  not  identical  effects  upon  the 
organism. 

Above  the  height  of  4000  metres  above  sea-level  (below 
460  millimetres  pressure)  the  profounder  disturbances  of  func- 
tion characterized  as  "  mountain  sickness  "  come  on.  Different 

1  Results  of  a  Scientific  Mission  to  India  and  High  Asia.  By  Hermann,  Adolpbe,  and 
Robert  De  Schlagintweit,  vol.  ii,  pp.  484,  485. 


INFLUENCE   OF   CHANGES   OF    ATMOSPHERIC   PRESSURE.  11 

individuals  react  in  different  degree  to  the  morbific  influences  of 
greatly  diminished  atmospheric  pressure  (and  coincident  reduc- 
tion of  oxygen).  Thus  Glaisher  reached  an  elevation  of  11,000 
metres  (191.1  millimetres  pressure)  and  returned  to  the  earth 
alive,  while  Croce-Spinelli  and  Sivel  perished  at  the  considerably 
lower  elevation  of  8000  metres,  equivalent  to  a  pressure  of  260 
millimetres  (7.2  per  cent,  of  oxygen). 

The  sanitarian  is  most  concerned  about  the  effects  of  press- 
ure of  the  atmosphere  from  760  millimetres  down  to  460  milli- 
metres (or  up  to  an  altitude  of  4000  metres  above  sea-level). 
The  climatotherapy  of  various  diseases  requires  that  the  effects 
of  variations  of  pressure  between  these  limits  should  be  carefully 
studied.  The  observations  of  Mermod  and  Jourdanet1  have 
illustrated  the  common  physiological  effects  of  these  circum- 
scribed changes,  while  the  experiences  of  therapeutists  have 
established  the  fact  very  clearly  that  many  cases  of  phthisis 
improve  markedly  in  a  rarefied  atmosphere.  Other  observers 
have  also  shown  that  the  effects  of  diminished  pressure  are  not 
always  beneficial,  and  Dr.  Loomis  has  warned  against  the  send- 
ing of  patients  with  heart  disease  to  high  altitudes.  Whether 
the  lethal  effects  that  have  been  recorded  in  such  cases  are  due 
to  the  increased  activity  of  the  heart  and  heightened  blood- 
pressure  from  deficient  oxygen,  or  as  suggested  by  Dr.  F.  Don- 
aldson, Jr.,  to  dilatation  of  the  heart- Avails  from  diminution  of 
external  pressure,  is  as  yet  unsettled.2 

It  is  probable  that  the  diurnal  or  accidental3  oscillations  of 
barometric  pressure  at  sea-level  have  no  appreciable  influence 
upon  the  organism.  The  statement  is  occasionally  met  that 
patients  subjected  to  grave  surgical  operations  oftener  do  badly 
during  low  atmospheric  pressure,  and  some  surgeons  never 

1  Jonrdanet  states  that  while  the  French  and  Belgian  soldiers  in  Mexico  had  an  accel- 
erated pulse,  the  natives  had  a  normal  pulse.  In  Mermod's  observations  the  average  frequency 
of  the  pulse  at  St.  Croix  (1106  metres  above  sea-level)  was  nearly  four  beats  greater  than  at  Strass- 
burgh  (142  metres).  The  condition  of  the  natives  at  the  high  settlements  of  the  Andes  and  Hima- 
layas has  not  yet  been  investigated  with  exactitude. 

*  American  Climatologkvil  Association,  Ib87. 

3  Meaning  the  oscillation  produced  by  storm  waves. 


12  TEXT-BOOK   OF   HYGIENE. 

operate  when  the  barometer  is  low  or  falling  if  they  can  avoid 
it.  An  inquiry  undertaken  by  the  writer  in  1876,  in  which  the 
excellent  records  of  the  Massachusetts  General  Hospital  and  the 
observations  of  the  Boston  station  of  the  United  States  Signal 
Service  for  five  years  were  used  as  the  basis  of  comparison, 
resulted  negatively.  The  deaths  following  operations  done  on 
days  when  the  barometer  was  high  or  rising  were  exactly  equal 
in  number  to  those  following  operations  when  the  barometer 
was  low  or  falling.  Unfortunately,  the  investigation  was  never 
pursued  to  the  extent  of  including  other  meteorological  elements, 
such  as  humidity,  cloudiness,  precipitation,  etc.  The  numerous 
studies  of  the  relations  of  variations  of  pressure  to  the  progress 
of  infectious  diseases  have  also  failed  to  yield  any  fruits  of  value. 
Whether  the  nerve-pains  so  frequently  complained  of,  especially 
by  elderly  patients,  during  the  progress  of  areas  of  low  barometer, 
are  due  to  the  diminished  pressure,  or  to  the  influence  of  some 
other  meteorological  factor,  such  as  humidity  or  electrical  con- 
dition, cannot  yet  be  decided. 

Increased  atmospheric  pressure,  as  noticed  in  caissons,  tun- 
nels, and  mines,  produces  increase  in  frequency  and  depth  of 
respiration,  diminution  in  the  number  of  beats  and  volume  of 
the  pulse,  pallor  of  the  skin,  increase  of  perspiration  (although 
Smith  states  that  this  is  only  apparent  and  due  to  lack  of  evapo- 
ration from  the  surface),  increased  appetite,  and  more  abundant 
excretion  from  the  kidneys. 

Among  the  distinctly  pathological  effects  of  increased  at- 
mospheric pressure  are  rupture  of  the  drum  of  the  ear,  pain  in 
the  frontal  and  maxillary  sinuses,  neuralgic  pains,  nausea,  some- 
times vomiting  and  local  paralyses.  Dr.  A.  H.  Smith1  defines 
this  collection  of  symptoms  as  "  The  Caisson  Disease,"  and  gives 
the  following  summary  of  its  characteristic  features : — 

"  A  disease  depending  upon  increased  atmospheric  pressure, 
but  always  developed  after  the  pressure  is  removed.  It  is  char- 

1  The  Physiological,  Pathological,  and  Therapeutical  Effects  of  Compressed  Air.  p  47. 
Detroit,  1886. 


INFLUENCE   OP   CHANGES   OF   ATMOSPHERIC   PRESSURE.  13 

acterized  by  extreme  pain  in  one  or  more  of  the  extremities,  and 
sometimes  in  the  trunk,  and  which  may  or  may  not  be  associated 
with  epigastric  pain  and  vomiting.  In  some  cases  the  pain  is 
accompanied  by  paralysis  more  or  less  complete,  which  may  be 
general  or  local,  but  is  most  frequently  confined  to  the  lower 
half  of  the  body.  Cerebral  symptoms,  such  as  headache  and 
vertigo,  are  sometimes  present.  The  above  symptoms  are  con- 
nected, at  least  in  the  fatal  cases,  with  congestion  of  the  brain 
and  spinal  cord,  often  resulting  in  serous  or  sanguineous  effu- 
sion, and  with  congestion  of  most  of  the  abdominal  viscera." 


INFLUENCE  OF  CHANGES  OF  TEMPERATURE  ON  HEALTH. 

Many  of  the  derangements  of  health  ascribed  to  high  tem- 
perature are  to  a  considerable  degree  due  to  other  factors,  promi- 
nent among  which  are  high  humidity,  intemperance,  overwork, 
and  overcrowding.  There  can  be  little  doubt,  however,  that  the 
importance  of  the  high  temperature  itself  can  hardly  be  over- 
rated. It  has  been  generally  accepted  heretofore  that  a  high 
temperature,  together  with  a  high  relative  humidity,  is  most 
likely  to  be  followed  by  sun-stroke.  A  careful  comparison  in  a 
series  of  deaths  from  sun-stroke  in  the  city  of  Cincinnati  in  the 
summer  of  1881  shows,  however,  conclusively  that  a  very  high 
mean  temperature  with  a  low  relative  humidity  is  more  liable  to 
be  followed  by  sun-stroke  than  the  high  temperature  when  ac- 
companied by  a  high  humidity.  The  same  series  of  observa- 
tions also  shows  that  the  number  of  deaths  was  greater  on  clear 
days  than  on  cloudy  or  partly  cloudy  days.1  A  corroboration 
of  this  result  is  found  in  the  fact  that  sun-strokes  very  rarely 
occur  on  shipboard,  at  sea,  where  the  relative  humidity  is 
always  high. 

The  direct  influence  of  the  sun's  rays  upon  the  skin  pro- 
duces at  times  an  erythcmatous  affection  which  may  run  into  a 

1  The  Run-stroke  Epidemic  of  Cincinnati,  O.,  during  the  Summer  of  1881.  A.  J.  Miles, 
Public  Health,  vol.  vii,  pp.  293-304. 


14  TEXT-BOOK   OF   HYGIENE. 

dermatitis  if  the  insolation  is  prolonged.  Artificial  heat  may 
produce  similar  effects. 

Diarrhceal  diseases,  both  of  adults  and  children,  are  much 
more  frequent  during  hot  than  cold  weather  (and  in  hot  than  in 
cold  climates),  but  it  is  probable  that  other  factors  aid  in  the 
production  of  these  diseases  besides  the  high  temperature. 

Certain  epidemic  diseases  are  likewise  more  frequent  in,  or 
exclusively  confined  to,  hot  climates.  These  are  cholera,  yellow 
fever,  and  epidemic  dysentery.  Elephantiasis,  malarial  fevers, 
and  certain  skin  diseases  seem  also  to  have  some  connection  with 
a  constantly  high  external  temperature.  The  intimate  relation 
between  cause  and  effect  is  not  clearly  understood,  although  the 
belief  is  current  that  the  origin  and  spread  of  such  diseases 
depend  upon  the  development  of  various  parasitic  organisms. 

Regarding  the  morbific  effects  of  continued  high  tempera- 
tures, it  is  probable  that  an  appropriate  mode  of  life,  proper 
diet,  and  suitable  clothing  would  avert  many  of  the  bad  conse- 
quences. Nevertheless,  the  fact  remains  that  certain  tropical  or 
hot-weather  diseases  must  be  considered  as  primarily  dependent 
upon  high  temperature,  although  the  pathological  effects  may  be 
due  to  an  intermediate  factor.  It  is  not  improbable  that  micro- 
organisms will  be  found  to  explain  yellow  fever,  cholera  infan- 
tum,  malarial  fever,  and  tropical  dysentery.  Cholera  has  already 
been  shown  to  depend  upon  a  pathogenic  organism.  In  this 
case  the  high  temperature  is  one  of  the  associate,  but  none  the 
less  indispensable,  factors  in  the  production  of  the  disease. 

Extreme  low  temperature,  as  observed  in  the  arctic  regions, 
seems  to  produce  a  progressive  deterioration  of  the  blood 
(anaemia),  in  consequence  of  which  most  natives  of  temperate 
regions  who  are  compelled  to  remain  in  the  far  north  longer 
than  two  winters  succumb  to  various  luemic  diseases,  scurvy  br- 
ing the  most  prominent.  It  is  not  improbable,  however,  that  the 
dietary  furnished  is  responsible  for  a  large  share  of  the  evil 
effects  ascribed  to  cold.  The  absence  of  sunlight  for  a  consider- 
able part  of  the  winter  season  may  also  have  much  to  do  with 


INFLUENCE    OF    CHANGES   OF    TEMPERATURE    ON    HEALTH.        15 

the  bad  influences  for  which  the  low  temperature  is  held 
responsible. 

Among  the  acute  effects  of  great  cold,  frost-bite  is  the  most 
frequent  as  well  as  the  most  serious.  Loss  of  portions  of  the 
nose,  or  ears,  or  even  of  entire  members  are  not  infrequent 
results  of  frost-bite. 

In  the  arctic  regions  one  of  the  most  annoying  affections 
which  the  traveler  has  to  contend  against  is  snow-blindness,  a 
severe  ophthalmia  produced  by  the  glare  of  the  snow.  Neutral 
tinted  glass  goggles  should  be  worn  as  a  preventive.1 

Ur.  Henry  B.  Baker2  has  placed  upon  record  a  large  mass 
of  observations  which  appear  to  indicate  that  most  of  the  acute 
diseases  of  the  respiratory  organs  are  caused  by  a  low  tempera- 
ture in  conjunction  with  a  low  absolute  humidity.  Dr.  Baker 
furnishes  numerous  diagrams,  which  seem  to  demonstrate  that 
the  curves  for  influenza,  tonsillitis,  croup,  bronchitis,  and  pneu- 
monia are  in  general  outlines  all  practically  the  same,  and  that 
they  follow  the  curve  for  atmospheric  temperature  with  surpris- 
ing closeness,  rising  after  the  temperature  falls  and  falling  after 
the  temperature  rises.  He  claims  that  this  sameness  indicates 
that  the  controlling  cause  is  one  and  the  same  for  all  of  these 
diseases,  and  that,  directly  or  indirectly,  the  atmospheric  tem- 
perature is  that  cause.  They  are  diseases  of  the  air-passages, 
and  may  be  supposed  to  be  influenced  or  controlled  by  the  at- 
mosphere which  passes  through  them.  Although  the  curves  are 
all  similar,  yet  their  differences  still  further  support  his  view, 
because  the  order  of  succession  of  the  several  diseases  is  such 
as  would  be  expected  if  caused  in  the  manner  which  he  sup- 
poses. Thus  croup  and  influenza  precede  in  time  bronchitis 
and  pneumonia ;  the  curve  for  bronchitis  shows  that  disease  to 
respond  quicker  than  does  pneumonia  to  the  rise  and  fall  of  the 

1  See  Payer's  Narrative  of  the  Austrian  Arctic  Voyage  of  1872-74,  pp.  250-3  and  317,  for  an 
account  of  the  effects  of  cold  on  the  organism,  and  on  the  best  prophylactic  measures  to  be 
adopted.  The  Report  of  the  Surgeon-General  of  the  U.  S.  Navy  for  1880  also  contains  (pp.  350-8) 
a  valuable  memorandum  by  Ex-Surgeon-General  Philip  S.  Wales,  on  Arctic  Hygiene. 

8  Trans.  Ninth  International  Med.  Congress,  vol.  v. 


16  TEXT-BOOK   OF   HYGIENE. 

temperature.  He  suggests  that  the  explanation  of  the  causa- 
tion of  these  diseases  has  not  been  grasped  before  because  one 
of  the  principal  facts  has  not  been  apprehended,  namely,  the 
fact  that  cold  air  is  always  dry  air ;  on  the  contrary,  it  has  been 
generally  stated  that  when  these  diseases  occur  the  air  is  cold 
and  damp.  He  explains  that  while  the  cold  air  is  damp  rela- 
tively it  is  always  dry  absolutely,  and  he  thinks  that  its  bad 
effects  on  the  air-passages  are  mainly  through  its  drying  effects, 
which  can  best  be  appreciated  by  reflecting  that  each  cubic  foot 
of  air  inhaled  at  the  temperature  of  zero,  F.  [ —  17.8°  C.],  can 
contain  only  J  grain  of  vapor  [1.33  grammes  per  cubic  metre], 
while  when  exhaled  it  is  nearly  saturated  at  a  temperature 
of  about  98°  F.  [36.5°  C.],  and  therefore  contains  about  18J 
grains  of  vapor  [about  43  grammes  per  cubic  metre],  about  18 
grains  of  which  have  been  abstracted  from  the  air-passages. 
Thus  cold  air  falling  upon  susceptible  surfaces  tends  to  produce 
an  abnormal  dryness  which  may  be  followed  by  irritation  and 
suppuration.  He  claims  that  coryza  is  sometimes  so  caused. 
Under  some  conditions  the  nasal  surfaces  are  not  susceptible  to 
drying,  the  fluids  being  supplied  in  increased  quantity  to  meet 
the  increased  demand  made  by  the  inhalation  of  cold  air.  In 
that'  case  an  unusual  evaporation  of  the  fluid  leaves  behind  an 
unusual  quantity  of  non-volatile  salts  of  the  blood,  such  as 
sodium  chloride,  and  an  unusual  irritation  results ;  he  thinks 
influenza  is  the  name  commonly  given  to  this  condition.  The 
effects  which  the  inhalation  of  cold  air  has  on  the  bronchial 
surfaces  depend  greatly  upon  how  the  upper  air-passages  have 
responded  to  the  increased  demand  for  fluids ;  because,  if  they  do 
not  supply  the  moisture  it  must  be  supplied  by  the  bronchial 
surfaces,  in  which  case  bronchitis  results.  Finally,  if  the  de- 
mands for  moisture  made  by  cold  air  are  not  met  until  the  air- 
cells  are  reached  pneumonia  is  produced. 

These  claims  are  partly  supported  and  partly  opposed  by 
an  elaborate  paper  by  Dr.  J.  W.  Moore.1     According  to  the 

1  The  Seasonal  Prevalence  of  Pneumonic  Fever,  Trans.  Ninth  Internat.  Congress,  vol.  v. 


INFLUENCE  OF  CHANGES  OF  TEMPERATURE  ON  HEALTH.    17 

statistics  furnished  by  this  writer,  bronchitis  and  pneumonia 
show  a  remarkable  contrast  as  to  seasonal  prevalence.  The  sta- 
tistics of  London  and  Dublin  agree  very  closely  upon  this  point. 
Bronchitis  falls  to  a  very  low  ebb  in  the  third  or  summer  quarter 
of  the  year  (July  to  September,  inclusive),  when  only  12  per 
cent,  of  the  deaths  annually  caused  by  this  disease  take  place 
in  Dublin  and  only  11  per  cent,  in  London.  In  the  last  or 
fourth  quarter  (October  to  December,  inclusive)  the  percentage 
of  deaths  from  bronchitis  rises  to  27  in  Dublin  and  30  in  London. 
The  maximal  mortality  occurs  in  the  first  quarter  (January  to 
March,  inclusive),  when  it  is  38  per  cent,  in  both  London  and 
Dublin.  In  the  second  or  spring  quarter  (April  to  June,  inclu- 
sive) the  bronchitic  deaths  decline  to  23  per  cent,  hi  Dublin  and 
21  per  cent,  in  London. 

The  mortality  from  pneumonic  fever  is  differently  distrib- 
uted throughout  the  year.  In  the  summer  quarter  more  than 
14  per  cent,  of  the  annual  deaths  referable  to  the  disease  are 
recorded  in  Dublin  and  more  than  15  per  cent,  in  London. 
In  the  first  quarter  the  figures  are — London,  31  per  cent.; 
Dublin,  31  per  cent.  In  the  second  quarter  they  are — London, 
26  per  cent. ;  Dublin,  30  per  cent.  In  the  fourth  quarter  they 
are — London,  27  per  cent. ;  Dublin,  24  per  cent. 

It  therefore  appears  that  the  prevalence  and  fatality  of  pneu- 
monic fever  from  season  to  season  do  not  correspond  with  the 
seasonal  prevalence  and  fatality  of  bronchitis.  The  latter  dis- 
ease increases  and  kills  in  direct  relation  to  the  setting  in  of  cold 
weather ;  it  subsides  in  prevalence  and  fatality  with  the  advance 
of  spring  and  the  advent  of  summer.  Pneumonic  fever,  on  the 
other  hand,  increases  less  quickly  in  winter  and  remains  more 
prevalent  in  spring  than  bronchitis ;  its  maximal  incidence  coin- 
cides with  the  dry,  harsh  winds  and  hot  sunshine  of  spring, 
when  the  diurnal  range  of  temperature  also  is  extreme. 

Dr.  Moore  believes  that  acute  bronchitis  is  produced  directly 
by  the  influence  of  low  temperature,  while  pneumonia  requires 
an  additional  cause,  which  he  supposes  to  be  a  specific  micro- 
organism. 2 


18  TEXT-BOOK   OF    HYGIENE. 

HUMIDITY   OF   THE   ATMOSPHERE    AS   CONNECTED    WITH    CHANGES    IN 

HEALTH. 

The  propagation  of  certain  acute  infectious  diseases  is  be- 
lieved to  be  due  to  a  high  relative  humidity.  There  can  be  no 
longer  any  doubt  that  a  very  humid  soil  and  air,  especially  if 
connected  with  a  variable  temperature,  are  almost  constant 
factors  in  the  production  of  pulmonary  phthisis.  Recent  experi- 
ence in  this  country  and  abroad  has  shown  that  the  high  plateaus 
and  mountains,  far  inland,  where  the  soil  is  dry  and  the  relative 
humidity  of  the  air  low,  are  the  best  resorts  for  consumptives. 

Of  the  effects  of  excessively  dry  air  on  health  little  definite 
is  known.  It  seems  probable,  however,  that  catarrhal  affections 
of  the  respiratory  mucous  membrane  are  more  frequent  in  a  dry 
than  in  a  humid  climate.1 

THE   SANITARY   RELATIONS   OF   AIR-CURRENTS. 

Primarily,  winds  or  air-currents  may  be  considered  as  favor- 
able to  health.  By  the  agitation  of  the  air  ventilation  is  secured, 
foul  air  removed  from  insanitary  places,  and  diluted  by  ad- 
mixture of  purer  air.  But  air-currents  may  also  be  regarded  as 
either  directly  or  indirectly  unfavorably  influencing  health. 
Vertical  currents  rising  from  the  ground  may  carry  morbific 
germs  or  viruses  and  give  rise  to  disease.  Horizontal  currents 
or  winds  proper  may  also  be  the  direct  or  indirect  cause  of  de- 
rangements of  health. 

Full  credit  is  given  by  the  public  to  cold  winds  and  draughts 
in  producing  catarrhs  and  rheumatic  pains.  The  progression  of 
certain  infectious  diseases,  especially  malaria,  is  believed  with 
good  reason  to  stand  in  a  definite  relation  with  the  direction  of 
the  wind. 

Certain  local  winds  are  known  to  have  a  deleterious  effect 
upon  living  beings,  especially  when  the  latter  are  in  bad  health. 
Among  these  winds  is  the  mistral,  a  cold,  dry,  parching  north- 

1  See  ante. 


SANITARY   RELATIONS   OF    AIR-CURRENTS.  19 

west  wind  which  blows  along  the  Gulf  of  Lyons.  It  brings  on 
rheumatism  and  muscular  pains,  and  is  said  to  excite  pleurisy 
and  pneumonia  and  to  act  unfavorably  upon  consumptives. 

The  bora  is  a  colol,  dry  wind  coming  down  from  the  Alps 
and  continuing  across  the  Adriatic. 

The  Texan  northers  are  well  known  in  the  southwestern 
part  of  the  United  States.  They  are  extremely  dry,  and  are 
often  accompanied  by  a  sudden  fall  of  temperature.  Changes 
of  28  °  C.  (50  °  F.)  within  twelve  hours  are  not  infrequent  in 
Western  and  Central  Texas.  Both  man  and  beast  suffer  in- 
tensely from  the  cold,  parching  character  of  the  wind. 

The  sirocco  of  Northern  Africa,  Sicily,  and  Southern  Italy 
has  a  wo  rid- wide  notoriety  for  its  depressing  effect  upon  human 
energy.  The  Jiarmattan  is  equally  noted  on  the  west  coast  of 
Africa.  It  is  hot  and  dry,  while  in  Southern  Europe  the  sirocco 
is  hot  and  moist. 

The  simoon  is  a  hot,  scorching  wind  of  India,  and  is  said 
to  be  deadly  in  its  effects  upon  vegetation  and  extremely  dele- 
terious to  men  and  animals  who  are  encountered  by  it.  In 
Australia  and  South  Africa  hot  winds  are  said  to  occur  which 
completely  destroy  vegetable  life  in  their  track,  and  are  often 
unwholesome  in  their  effects  upon  animal  life. 

The  evil  reputation  of  the  Alpine  fohn  is  very  well  known, 
and  neither  native  nor  traveler  is  anxious  to  encounter  it.  It  is 
warm  and  dry. 

With  reference  to  the  influence  of  electrical  conditions  of 
the  atmosphere  upon  health,  no  observations  have  been  made 
which  justify  definite  conclusions.1 

Mr.  Alexander  Buchan  and  Dr.  Arthur  Mitchell  have 
analyzed  the  influence  of  the  weather  and  season  upon  the 

1  Dr.  S.  Weir  Mitchell  has  shown,  from  the  record  of  the  case  of  Captain  Catlin,  U.  S.  A. 
(American  Journal  Med.  Sci.,  April,  1877,  and  N.  Y.Med.  Jour.,  August  25  and  September  1, 1883), 
that  attacks  of  neuralgia— in  this  case,  at  all  events— accompanied  the  progress  of  storms  across 
the  continent.  Also,  that  the  periods  of  maximum  pain  occurred  with  a  high  but  falling  barom- 
eter and  increasing  absolute  humidity.  There  seems  also  to  be  some  relation  in  this  case  between 
the  maximum  pain  and  the  maximum  magnetic  force  as  shown  by  the  declinometer.  Dr. 
Mitchell's  papers  are  among  the  most  valuable  positive  contributions  to  hygienic  meteorology, 
and  deserve  careful  study. 


20  TEXT-BOOK   OF    HYGIENE. 

causation  of  disease,  or,  rather,  upon  the  mortality  from  various 
diseases.1  Taking  the  records  of  the  city  of  New  York  from 
1871  to  1877,  it  appears  that  the  maximum  number  of  deaths 
from  small-pox  occurred  in  May,  the  minimum  in  September. 
From  measles  there  were  two  annual  maxima  and  minima,  the 
greater  in  July  and  September  and  the  smaller  in  February  and 
April.  From  scarlet  fever  the  maximum  was  in  April,  the  mini- 
mum in  September.  From  typhoid  fever  the  maximum  was 
from  August  to  November,  the  minimum  almost  equally  distrib- 
uted throughout  the  rest  of  the  year ;  from  diarrhoea,  the  maxi- 
mum in  July  and  August,  the  minimum  from  December  to 
March ;  from  diphtheria,  the  maximum  in  December,  the  mini- 
mum in  August ; 2  from  whooping-cough,  maximum  in  Septem- 
ber and  February,  minimum  in  November  and  June ;  for  croup 
the  curves  agree  pretty  closely  with  the  diphtheria  curves ;  from 
phthisis,  the  maximum  in  March,  minimum  in  June. 

The  following  charts,  reproduced  by  permission  of  the 
Massachusetts  State  Board  of  Health  from  the  report  of  that 
body  for  1888,  show  an  almost  identical  movement  of  the 
mortality  from  different  diseases  throughout  the  year.  They 
exhibit  the  reported  mortality  for  1888  and  also  for  the  six  years 
from  1883  to  1888. 

From  suicide,  curiously,  the  greater  number  of  deaths  occurs 
in  May,  the  smallest  in  February.  This  is  contrary  to  the  usual 
supposition  that  gloomy  weather  predisposes  to  suicide.  The  six 
summer  months — from  April  to  September — show  a  much  larger 
number  of  self-murders  than  the  remaining  half-year.  In  eleven 
years,  ending  1880,  there  were  1521  cases  of  self-destruction  in 
New  York.  Of  these  341  occurred  during  January,  February, 
and  March;  417  during  April,  May,  and  June;  412  during 
July,  August,  and  September;  and  351  during  the  last  three 
months  of  the  year.  In  Philadelphia,  the  results  of  examination 

1  Journal  Scottish  Meteorological  Society,  1875-78.  (Abstract  in  Richardson's  Prevent- 
ive Medicine,  p.  533  et  seq.  Philadelphia,  1884.) 

a  See  paper  on  the  Relation  of  Weather  to  Mortality  from  Diphtheria  in  Baltimore, 
by  Richard  Henry  Thomas,  in  Trans.  Med.  and  Chir.  Faculty  of  Maryland,  1883. 


INFLUENCE    OF    SEASON    UPON    MORTALITY. 


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26  TEXT-BOOK   OF   HYGIENE. 

of  the  statistics  of  suicide  for  ten  years  are  almost  exactly 
similar.  Out  of  636  cases  of  suicide,  78  occurred  in  May,  71  in 
August,  57  in  December,  54  each  in  October,  July,  and  April, 
52  in  June,  49  in  November,  44  each  in  December  and  Feb- 
ruary, 43  in  March,  and  36  in  January.1  Dr.  Lee  is  led  to  be- 
lieve that  "  a  low  barometric  pressure,  accompanied  by  a  high 
thermometric  registry,  with  sudden  fluctuations  from  a  low  to  a 
high  temperature,  together  with  much  moisture  and  prevailing 
southwest  winds,  might  somewhat  account  for  the  frequency  of 
self-murder  in  the  spring  and  summer  months." 

THE   SANITARY    RELATIONS    OF   CHANGES    IN    COMPOSITION    AND    OF 
IMPURITIES  IN   THE   AIR. 

The  average  proportion  9f  carbon  dioxide  in  the  atmosphere 
is  from  3  to  4  parts  in  10,000.  Pettenkofer2  places  the  maxi- 
mum limit  of  carbon  dioxide  allowable  in  the  air  of  dwellings 
at  7  parts  in  10,000.  It  is  probable  that  this  limit  is  very  fre- 
quently exceeded  without  serious  consequences  to  health,  if  the 
air  is  not  at  the  same  time  polluted  by  organic  impurities,  the 
products  of  respiration.  Prof.  William  Ripley  Nichols  found 
the  air  in  a  school-room  in  Boston  to  contain  eight  times  the 
normal  proportion  of  carbon  dioxide,  while  Pettenkofer  found, 
also  in  a  school-room,  after  the  same  had  been  occupied  two 
hours,  eighteen  times  the  normal  proportion,  or  72  parts  in 
10,()00.3  While  such  an  excess  of  this  poisonous  gas  must 
unquestionably  have  an  unfavorable  influence  upon  health,  it  is 
probable  that  the  most  serious  effects  are  due  to  the  coincident 
diminution  of  oxygen  and  the  pollution  of  the  air  by  the  prod- 
ucts of  respiration  which  necessarily  take  place  during  respira- 
tion. Carbon  dioxide  alone  may  be  present  in  the  air  to  a  much 
greater  extent  than  above  mentioned  without  causing  any  appre- 
ciable inconvenience.  In  the  air  of  soda-water  manufactories 

1  Suicide  in  the  City  and  County  of  Philadelphia  during  a  Decade,  1872  to  1881,  inclusive, 
by  John  G.  Lee,  Trans.  Am.  Med.  Asso.,  vol.  xxxiii,  p.  425. 

8  Quoted  in  Buck's  Hygiene  and  Public  Health,  vol.  i,  p.  615. 
3  See  table  in  Buck's  Hygiene  and  Public  Health,  vol.  i,  p.  612. 


SANITARY    RELATIONS   OF    IMPURITIES   IN   THE   AIR.  27 

there  is  frequently  as  large  a  proportion  as  2  per  cent,  of  this 
gas  present  without  producing  any  ill  effects  upon  those  breathing 
such  an  atmosphere. 

The  amount  of  carbon  dioxide  in  the  atmosphere  is  greatest 
at  night.  It  is  also  greater  very  near  the  ground  than  at  a  dis- 
tance of  several  feet  above  it.  As  carbon  dioxide  is  absorbed 
by  the  leaves  of  plants  during  the  day-time,  but  given  off  at 
night,  the  difference  may  partly  be  thus  accounted  for.  Accord- 
ing to  Fodor,1  the  source  of  a  large  proportion  of  the  carbon 
dioxide  in  the  air  is  the  decomposition  going  on  in  the  soil. 
This  accounts  for  the  larger  percentage  of  carbon  dioxide  near 
the  ground.  This  would  also  explain  the  variation  of  the  pro- 
portion of  carbon  dioxide  in  the  air  under  different  meteoro- 
logical conditions.  For  example,  it  is  found  that  during  rainy 
weather  the  carbon  dioxide  in  the  air  is  diminished.  This  is 
accounted  for  partly  by  the  absorption  of  the  carbon  dioxide 
by  the  saturated  ground,  while  at  the  same  time  the  porosity 
of  the  soil  is  diminished  and  the  escape  of  the  ground-air 
prevented. 

Mr.  R.  Angus  Smith  made  a  number  of  'experiments  upon 
himself  to  determine  the  effects  of  an  atmosphere  gradually 
becoming  charged  with  the  products  of  respiration  and  per- 
spiration. His  experiments  were  conducted  in  a  leaden  cham- 
ber holding  5  cubic  metres  of  air.  This  air  was  not  changed 
during  the  experiment.  After  remaining  for  an  hour  in  this 
chamber,  an  unpleasant  odor  of  organic  matter  was  perceptible 
on  moving  about.  The  air,  when  agitated,  felt  soft,  owing, 
doubtless,  to  the  excess  of  moisture  contained  in  it.  The  air 
soon  became  very  foul,  and,  although  not  producing  any  dis- 
comfort, the  experimenter  states  that  escape  from  it  produced  a 
feeling  of  extreme  pleasure,  like  "  that  which  one  has  when 
walking  home  on  a  fine  evening  after  leaving  a  room  which  has 
been  crowded." 

1  Hygienische  Untersuchungen  ueber  Luft,  Boden  and  Wasser,  Braunschweig.  1882, 
2te  Abth. 

»  Air  and  Rain,  p.  138. 


28  TEXT-BOOK   OF   HYGIENE. 

Hammond  l  confined  a  mouse  in  a  large  jar  in  which  were 
suspended  several  large  sponges  saturated  with  baryta  water,  to 
remove  the  carbon  dioxide  as  rapidly  as  formed.  Fresh  air  was 
supplied  as  fast  as  required.  The  aqueous  vapor  exhaled  was 
absorbed  by  calcium  chloride.  The  mouse  died  in  forty-five 
minutes,  evidently  from  the  effect  of  the  organic  matter  in  the 
air  of  the  jar.  The  presence  of  this  organic  matter  was  demon- 
strated by  passing  the  air  through  a  solution  of  potassium  per- 
manganate. 

The  horrible  story  of  the  "  black  hole "  of  Calcutta  is 
familiar  to  every  one.  Of  146  prisoners  confined  in  a  dark  cell 
at  night,  23  were  found  alive  in  the  morning.  Among  the  sur- 
vivors a  fatal  form  of  typhus  fever  broke  out,  which  carried  off 
nearly  all  of  them.  After  the  battle  of  Austeiiitz  300  prisoners 
were  crowded  in  a  prison ;  260  died  in  a  short  time  from  inhal- 
ing the  poisoned  air.  Numerous  other  similar  examples  of  the 
effects  of  polluted  air  are  recorded. 

Usually  the  effects  of  foul  air  are  not  so  sudden  and  strik- 
ing. In  most  instances,  especially  where  the  pollution  has  not 
reached  a  high  degree,  there  simply  results  a  general  deficiency 
of  nutrition,  which  manifests  itself  in  anaemia,  loss  of  vigor  of 
body  and  mind,  and  a  gradual  diminution  of  resistance  to 
disease. 

It  seems  to  be  beyond  question  that  persons  who  are  con- 
stantly compelled  to  inhale  impure  air,  especially  if  combined 
with  an  improper  position  of  the  body  or  lack  of  sufficient  or 
appropriate  food,  furnish  a  very  large  percentage  of  chronic  pul- 
monary affections.  Phthisical  patients,  in  the  overwhelming 
majority  of  cases,  are  drawn  from  the  classes  whose  occupations 
keep  them  confined  in  close  rooms.  Want  of  exercise  and  of 
good  food  doubtless  aid  in  the  development  of  the  lung  disease. 
Formerly,  when  less  attention  was  paid  to  the  proper  construc- 
tion and  ventilation  of  barracks  and  prisons,  the  mortality  from 

1  A  Treatise  on  Hygiene,  with  Special  Reference  to  the  Military  Service,  by  William  A. 
Hammond,  M.D.,  Surgeon-General  U.  S.  Army,  p.  170.  Philadelphia,  1863. 


SANITARY   RELATIONS   OF   IMPURITIES   IN   THE   AIR.  29 

phthisis  among  soldiers  and  criminals  was  much  greater  than  it 
is  now.  In  animals  kept  closely  confined  the  same  disease  claims 
a  large  share  in  the  mortality. 

Near  the  end  of  the  last  century  over  one-third  of  the  in- 
fants born  in  the  old  Dublin  Lying-in  Hospital  died  of  epidemic 
diseases.  After  the  adoption  of  an  improved  system  of  ventila- 
tion the  mortality  fell  to  about  one-tenth  of  what  it  had  pre- 
viously been.  To  illustrate  the  effect  of  similar  conditions  upon 
the  health  of  domestic  animals,  the  following  instance  is  cited : 
Upward  of  thirty  years  ago  a  severe  epidemic  of  influenza  in 
horses  appeared  in  Boston.  At  the  instigation  of  Dr.  H.  I. 
Bowditch,  every  stable  in  the  city  was  inspected,  and  classified 
as  "  excellent,"  "  imperfect,"  or  "  wholly  unfit,"  in  respect  to 
warmth,  dryness,  light,  ventilation,  and  cleanliness.  It  was 
found  that  in  the  first  class  fewer  horses  were  attacked  and  the 
disease  was  milder,  while  in  the  third  class  every  horse  was 
attacked  and  the  more  severe  and  fatal  cases  occurred. 

Carbon  monoxide  is  a  very  dangerous  impurity  often 
present  in  the  air  of  living-rooms.  Being  an  ingredient  of 
illuminating  gas,  as  well  as  the  so-called  coal-gas,  which  so 
frequently  escapes  from  stoves  and  furnaces,  its  dangerous  char- 
acter becomes  apparent.  Many  persons  die  every  year  in  this 
country  from  the  inhalation  of  illuminating  gas.  People  un- 
acquainted with  the  mechanism  of  the  gas-fixtures  frequently 
blow  out  the  light  instead  of  cutting  off  the  supply  of  gas  by 
turning  the  stop-cock.  It  is  also  a  prevailing  custom  to  keep 
the  light  burning  "  low  "  during  the  night.  Any  considerable 
variation  of  pressure  in  the  pipes,  or  sudden  draught,  may  put 
out  the  light  and  permit  the  gas  to  escape  into  the  room,  with 
fatal  effect.  Leaks  in  pipes  or  fixtures  may  have  the  same  results. 

Coal-,  coke-,  or  charcoal-  fires  may  produce  serious  or  fatal 
poisoning  if  the  gas,  which  contains  a  large  proportion  of  car- 
bon monoxide,  is  permitted  to  escape  into  the  room.1  In 

>  See  paper  by  Dr.  John  Graham  in  Transactions  of  Philadelphia  College  of  Physician* 
for  1885. 


30  TEXT-BOOK   OF   HYGIENE. 

certain  parts  of  Europe,  notably  in  France,  the  inhalation  of  the 
fumes  of  a  charcoal  fire  is  a  favorite  method  of  committing 
suicide. 

The  gas  which  sometimes  escapes  from  the  stove  when  coal 
is  burning  has  the  following  composition : — 

Carbon  dioxide, 6.75  per  cent. 

Carbon  monoxide, 1.34       " 

Oxygen, 13.19       " 

Nitrogen, 79.72       " 

Sulphuretted  and  carburetted  hydrogen  are  not  infrequently 
present  in  the  air,  especially  about  cess-pools  and  in  mines  and 
certain  manufacturing  establishments.  Sulphuretted  hydrogen 
is  generally  considered  to  be  a  violent  poison,  but  there  is  no 
evidence  that  it  is  so  unless  oxygen  is  excluded. 

Carburetted  hydrogen  is  the  so-called  "fire-damp"  of 
mines,  which  is  so  often  the  cause  of  fatal  explosions.  Its  in- 
halation does  not  seem  to  be  especially  noxious.  It  will  be 
more  fully  referred  to  in  a  succeeding  chapter. 

Variations  in  the  proportion  of  ammonia  present  in  the  air 
are  frequent.  Its  presence  is  an  indication  of  organic  decom- 
position in  the  vicinity,  but  nothing  is  known  of  the  influence 
of  the  gas  itself  upon  health,  in  the  proportion  in  which  it  is 
ever  found  in  the  atmosphere. 

SEWER-AIR. 

Sewer-air,  or  sewer-gas,  as  it  is  often  improperly  called,  is 
a  variable  mixture  of  a  number  of  gases,  vapors,  atmospheric 
air,  and  solid  particles,  and  is  derived  from  the  decomposition  of 
the  animal  and  vegetable  contents  of  sewers.  A  number  of 
analyses  by  different  chemists  have  shown  that  the  composition 
of  sewer-air  is  extremely  variable.  The  most  important  com- 
ponents, in  addition  to  the  constituents  of  atmospheric  air,  are  : 
Carbon  dioxide,  ammonia,  sulphuretted  hydrogen,  and  a  number 
of  volatile  organic  compounds,  which  give  to  sewage  its  peculiar 
odor,  but  which  are  present  in  such  small  quantity  as  to  prevent 


SfcWER-AIR.  31 

accurate  determination  by  chemical  means.  Sewer-air  may  also 
contain  particulate  bodies,  bacteria,  and  other  microscopic  or- 
ganisms, which  are  supposed  by  many  to  be  the  active  causes 
of  infectious  diseases.  Some  recent  researches  by  Carnelly  and 
Haldane  have  shown  that  sewer-air  usually  contains  a  less 
number  of  micro-organisms  than  the  external  air  of  cities.  The 
proportion  of  carbon  dioxide  found  was  also  much  less  than  was 
expected.  When  the  contents  of  sewers  remain  in  these  re- 
ceptacles or  conduits  long  enough  to  undergo  decomposition, 
sewer-air  is  always  present.  It  is  believed  by  some  physicians 
and  sanitarians  that  sewer-air  is  the  direct  cause  of  such  diseases 
as  typhoid  fever,  scarlet  fever,  diphtheria,  and  cholera,  while 
others  hold  the  view  that  the  sewer-air  is  merely  a  favorable 
breeding-place  for  the  germs  of  these  diseases,  and  that  it  thus 
merely  acts  as  a  medium  in  which  the  infective  agent  grows,  re- 
produces itself,  and  is  conveyed  from  place  to  place.  There  is 
no  absolutely  trustworthy  evidence  in  favor  of  either  of  these 
doctrines. 

It  is  hardly  open  to  question,  however,  that  the  continual 
breathing  of  air  polluted  by  emanations  from  sewers  often  pro- 
duces more  or  less  serious  derangements  of  health.  Diarrhoea 
and  other  intestinal  affections,  mild  cases  of  continued  fever,  and 
even  cases  of  undoubted  typhoid  fever  have  been  so  frequently 
noted  in  connection  with  defective  sewerage,  and  the  escape  of 
sewer-air  into  inhabited  rooms,  that  doubt  upon  this  point  is 
hardly  justifiable.  With  regard  to  typhoid  fever,  however,  it  is 
probable  that  the  sewage  in  these  cases  contained  the  particular 
virus  (bacillus  ?)  which,  it  is  now  generally  believed,  causes  this 
disease. 

The  effluvia  from  cemeteries,  knackeries,  and  other  places 
where  the  bodies  of  animals  are  undergoing  decomposition,  are 
popularly  regarded  as  deleterious  in  their  effects  upon  health. 
The  evidence  in  favor  of  this  view  is,  however,  very  indefinite. 

Professor  Tyndall   has  shown l  that  even  the  apparently 

1  Essays  on  Floating  Matter  of  the  Air.    New  York,  1882. 


32  TEXT-BOOK   OF   HYGIENE. 

clearest  air  is,  when  in  motion,  constantly  filled  with  innumerable 
particles  of  dust,  which  are  believed  by  many  to  give  rise  to 
various  forms  of  disease.  The  presence  of  these  particles  can 
be  easily  demonstrated  by  means  of  the  electric  light.  Every 
one  has  observed  these  minute  particles  in  a  bright  ray  of  sun- 
light. Under  ordinary  conditions  these  particles  of  dust  would, 
of  course,  give  rise  to  no  trouble,  but,  if  intermingled  with  these 
dust-specks  there  were  disease  germs, — whether  these  germs  be 
considered  as  living  organisms,  or  as  particles  of  dead  tissue 
from  the  body, — then  manifestly  the  inhalation  of  such  "dust" 
would  be  dangerous.1 

The  quantity  of  dust  found  in  the  air  of  cities  is  much 
greater  than  in  the  country.  Tissandier  found  that  in  Paris  the 
percentage  of  dust  was  eight  to  twelve  times  greater  than  in  the 
open  country.  One-fourth  to  nearly  one-half  of  this  atmos- 
pheric dust  is  organic,  either  animal  or  vegetable.  Very  recent 
observations  have  shown  that  in  Paris  the  air  contains  nine  or 
ten  times  as  many  bacteria  in  a  given  volume  as  the  air  at  the 
observatory  of  Montsouris,  just  without  the  city.  The  relative 
proportions  of  organic  and  inorganic  particles  vary  as  25  to  75 
in  Paris,  45  to  55  in  Dublin,  and  25  to  75  in  the  open 
country.  The  organic  particles  are  either  particles  of  dead  or- 
ganic matter,  or  minute  organisms.  The  proportion  of  the 
latter  varies  in  different  seasons,  being  least  in  winter  and 
spring,  and  greatest  in  summer  and  autumn.  These  organisms 
are  not  necessarily  pathogenetic,  but  the  conditions  which  favor 
the  proliferation  of  non-pathogenic  bacteria  are  likely  to  promote 
the  development  of  disease-producing  ones  likewise. 

Among  the  pathogenic  micro-organisms  found  in  the  at- 
mosphere are  spores  of  achorion  Schoenleinii,  the  so-called  ma- 
laria bacillus  of  Klebs  and  Tommasi-Crudeli,  and  Fehleisen's 
erysipelas  germ.  It  is  probable,  also,  that  the  bacilli  of  tuber- 
culosis, cholera,  and  typhoid  fever,  and  other  organisms,  at  times 

1  See  Chapter  IX,  on  Industrial  Hygiene,  for  effects  of  inhalation  of  dust  in  various 
industries. 


SEWER-AIR.  33 

undergo  multiplication  in  the  air,  and  that  the  latter  may  be  the 
medium  of  communication  of  these  diseases.  But  it  must  be 
admitted  that  our  knowledge  upon  this  point  is  at  present 
rather  vague  and  unsatisfactory. 

As  regards  the  diseases  that  may  be  produced  by  the  in- 
halation of  pathogenic  organisms  there  can  be  no  doubt  that 
diphtheria,  glanders,  measles,  scarlet  fever,  whooping-cough,  in- 
fectious pneumonia,  and,  above  all,  pulmonary  tuberculosis,  are 
so  caused.  It  is  likewise  probable  that  yellow  fever,  epidemic 
influenza,  cholera,  and  typhoid  fever  may  be  produced  in  this 
manner. 

TESTS  FOR   IMPURITIES  IN   THE   AIR. 

The  sense  of  smell  will  indicate  the  presence  of  sulphu- 
retted hydrogen,  or  of  volatile  organic  matter.  Chemical  tests 
and  the  microscope  will,  however,  be  necessary  to  determine  the 
presence  of  carbon  dioxide,  carbon  monoxide,  or  suspended 
particulate  matter  in  the  air. 

In  order  to  detect  the  presence  of  carbon  dioxide,  advantage 
is  taken  of  the  affinity  of  this  compound  for  certain  alkalies 
with  which  it  forms  insoluble  compounds.  If  a  stream  of  carbon 
dioxide  gas  is  passed  through  lime-  or  baryta-  water,  an  insoluble 
carbonate  of  lime  or  baryta  is  instantly  formed,  and  produces  a 
milky  precipitate  in  the  water.  If,  instead  of  passing  a  stream 
of  gas  through  the  liquid,  the  latter  be  agitated  with  air  con- 
taining carbon  dioxide,  a  similar  precipitate  is  produced.  The 
most  exact  method  of  determining  the  amount  of  carbon  dioxide 
in  the  air  is  that  known  as  Pettenkofer's,1  but  it  is  somewhat 
complicated.  A  readier  method  has  been  devised  by  Mr.  Angus 
Smith,  and  is  termed  the  minimetric  test.2  A  series  of  six  wide- 
mouthed  bottles,  having  a  capacity  respectively  of  450,  350,  300, 
250,  200,  and  150  cubic  centimetres,3  is  fitted  with  clean,  tightly- 

1  Lehrbuch  der  Hygiene,  Nowak,  p.  149. 
»  Op.  cit.,  p.  152. 

3  The  equivalents  in  English  measures  are  14  ounces.  11  ounces,  9^£  ounces,  8  ounces,  &£ 
ounces,  and  4%  ounces. 

3 


34 


TEXT-BOOK    OF    HYGIENE. 


fitting  corks.  The  bottles  are  made  perfectly  clean  and  dry, 
and  15  cubic  centimetres  (3£  drachms)  of  clear,  fresh  lime-  or 
baryta-  water  put  into  the  smallest,  the  cork  replaced,  and  the 
bottle  well  shaken.  If  the  water  becomes  turbid  there  is  at 
least  .16  per  cent.  (16  parts  per  10,000)  of  carbon  dioxide 
in  the  air  treated.  If  only  the  water  in  the  largest  bottle 
becomes  cloudy,  the  proportion  of  carbon  dioxide  is  probably 
less  than  5  parts  in  10,000.  For  the  intermediate  series  of 
bottles  the  amounts  of  carbon  dioxide  necessary  to  produce 
cloudiness  are,  respectively:  For  200  cubic  centi- 
metres of  air,  12  parts  in  10,000;  for  250  cubic 
centimetres,  10  parts;  for  300  cubic  centimetres, 
8  parts;  and  for  350  cubic  centimetres,  7  parts  per 
10,000.  If,  therefore,  a  cloudiness  is  produced  with 
any  of  the  bottles  except  the  largest,  the  amount 
of  carbon  dioxide  present  exceeds  the  standard 
allowable  in  pure  air.  The  test  should  be  frequently 
made,  in  order  to  acquire  familiarity  with  its  use. 
The  same  quantity  of  the  test-liquid  is,  of  course, 
used  in  each  bottle. 

A  simple  and  easily-managed  instrument, 
called  an  "  air-tester,"  has  been  devised  by  Professor 
Wolpert,  a  distinguished  German  meteorologist.  It 
is  described  as  follows  by  Dr.  S.  W.  Abbott,  who 
first  called  attention  to  its  merits  in  this  country1: 
The  little  instrument  consists  of  a  simple  rubber  bulb 
(A)  of  a  capacity  of  28  cubic  centimetres,  a  glass  outlet-tube  (B) 
with  a  constriction  near  its  extremity  (E).  A  glass  test-tube, 
12  centimetres  in  length  (C)  and  2  millimetres  in  diameter,  has 
a  horizontal  mark  near  the  bottom,  indicating  the  point  to  which 
it  must  be  filled  with  perfectly  clear  lime-water,  to  contain 
3  cubic  centimetres.  The  bottom  of  the  tube  is  whitened  and 
has  a  black  mark  stamped  upon  it  (D).  A  small,  wooden  stand, 
a  brush  or  swab,  a  vial  of  vinegar  for  cleaning  the  tube,  and  a 
bottle  of  clear  lime-water  complete  the  outfit. 

1  Boston  Mecl.  and  Surg.  Journal. 


FIG.  2. 
AIR-TESTER. 


TESTS   FOR   IMPURITIES   IN   THE   AIR.  35 

In  order  to  use  the  instrument,  the  lime-water  (saturated 
solution)  should  be  poured  into  the  test-tube  till  it  reaches  the 
horizontal  mark.  Press  down  the  bulb  with  the  thumb,  so  as 
to  expel  the  air  within  it  as  completely  as  possible,  and  allow  it 
to  fill  with  the  air  of  the  apartment,  insert  the  small  tube  into 
the  lime-water  nearly  to  the  bottom,  and  again  expel  the  air 
with  moderate  rapidity,  so  that  the  bubbles  may  rise  nearly  to 
the  top  of  the  tube,  but  do  not  overflow,  taking  care  to  continue 
the  pressure  of  the  thumb  till  the  small  tube  is  removed  from 
the  lime-water.  Repeat  this  process  until  the  mark  upon  the 
bottom  of  the  test-tube  is  obscured  by  the  opacity  produced  by 
the  reaction  of  the  carbonic  acid  upon  the  lime-water,  the  observer 
looking  downward  through  the  lime-water  from  the  top  of  the 
test-tube. 

With  very  foul  air  it  is  necessary  to  examine  the  mark  after 
filling  and  discharging  the  bulb  a  few  times  only;  with  good  air, 
it  must  be  filled  twenty-five  times  and  upward. 

The  bulb  represented  in  the  cut  is  made  a  little  larger  than 
the  required  capacity,  since  a  small  amount  of  residual  air 
usually  remains  in  the  bulb  and  cannot  be  expelled  without 
great  care. 

After  each  observation,  the  test-tube  must  be  washed  out 
and  wiped  dry.  If  a  white  incrustation  forms  upon  the  tube,  it 
may  be  easily  removed  with  a  little  vinegar,  after  which  the 
tube  should  be  thoroughly  washed  with  pure  water  and  dried. 

If  the  mark  becomes  obscured  after  filling  the  bulb  ten  or 
fifteen  times  only,  the  air  of  an  apartment  is  unfit  for  continuous 
respiration. 

In  a  sick-chamber  the  air  should  be  so  pure  that  the  tur- 
bidity of  the  lime-water  will  not  render  the  mark  invisible  until 
thirty  or  forty  fillings  are  made. 

The  instrument  should  be  used  by  daylight,  over  a  white 
ground,  as  a  sheet  of  writing-paper,  and  care  should  be  taken 
not  to  vitiate  the  result  by  the  observer's  own  breath. 

The  following  approximate  table  is  taken  from  the  article 


36 


TEXT-BOOK   OF   HYGIENE. 


by  Professor  Wolpert,  the  first  column  representing  the  number 
of  fillings  of  the  bulb,  and  the  second  column  the  parts  per 
10,000  of  carbon  dioxide  in  a  given  sample  of  air: — 


Number  of 
Fillings. 

Carbon  Dioxide 
per  10,000. 

Number  of 
Fillings. 

Carbon  Dioxide 
per  10,000. 

Number  of 
Fillings. 

Carbon  Dioxide 
per  10,000. 

1 

200. 

21 

9.5 

41 

4.9 

2 

100. 

22 

9.1 

42 

4.8 

3 

67. 

23 

8.7 

43 

4.6 

4 

50. 

24 

8.3 

44 

4.5 

5 

40. 

25 

8. 

45 

4.4 

6 

33. 

26 

7.7 

46 

4.3 

7 

29. 

27 

7.4 

47 

4.2 

8 

25. 

28 

7.1 

48 

4.1 

9 

22. 

29 

6.9 

49 

4.1 

10 

20. 

30 

6.6 

50 

4. 

11 

18. 

31 

6.4 

51 

3.9 

12 

16. 

32 

6.3 

52 

3.9 

13 

15. 

33 

6.1 

53 

3.8 

14 

14. 

34 

5.9 

54 

3.7 

15 

13. 

35 

5.7 

55 

3.7 

16 

12.5 

36 

5.5 

56 

3.6 

17 

12. 

37 

5.4 

57 

3.5 

18 

11. 

38 

5.3 

58 

3.5 

19 

10.5 

39 

5.1 

59 

3.4 

20 

70. 

40 

5. 

60 

3.3 

Carbon  monoxide  is  detected  by  its  reaction  with  palladium 
chloride,  which  gives  a  black  color  when  brought  in  contact 
with  the  gas.  If  a  strip  of  linen  or  blotting-paper  be  moistened 
with  a  solution  of  the  palladium  chloride  (1  to  500)  and  sus- 
pended in  air  containing  carbon  monoxide,  the  black  color  will 
be  developed.  The  suspected  air  may  also  be  passed  through  a 
solution  of  sodio-chloride  of  palladium,  when  the  liquid  will 
turn  black  if  carbon  monoxide  be  present. 

The  percentage  of  organic  impurity  in  the  air  of  an  occu- 
pied room  (products  of  respiration,  etc.)  is  difficult  to  ascertain 
directly. 

Pettenkofer  has  found,  however,  that  the  proportion  of 
carbon  dioxide  present  is  indirectly  a  measure  of  the  organic 
impurity  from  respiration.  As  the  determination  of  the  carbon 


TESTS   FOR   IMPURITIES   IN   THE   AIR.  37 

dioxide  is  easy  by  the  minimetric  method  of  Angus  Smith,  or 
the  ready  method  of  Wolpert,  the  extent  to  which  the  air  is 
polluted  by  respiratory  impurities  is  readily  ascertained.1 

The  presence  of  organic  and  other  suspended  impurities 
can  be  best  demonstrated  with  a  microscope.  An  objective,  mag- 
nifying upward  of  400  linear  diameters,  and  experience  in  the 
use  of  the  instrument  will  be  needed  to  obtain  correct  results. 
By  moistening  a .  glass  slide  with  glycerin  and  exposing  it  in 
the  suspected  air,  a  sufficient  quantity  of  the  suspended  matters 
may  be  collected  in  the  course  of  twenty-four  hours  to  permit 
some  conclusions  to  be  drawn  from  a  microscopic  examination.2 

A  common  method  of  determining  the  presence  or  absence 
of  a  large  quantity  of  carbon  dioxide,  for  example,  at  the  bottom 
of  a  well  or  privy-vault  is  to  lower  a  lighted  candle  to  the 
bottom.  If  the  light  is  extinguished,  the  air  is  considered  irre- 
spirable ;  but,  if  it  continue  burning  brightly,  the  air  is  believed 
to  be  sufficiently  pure  to  sustain  life.  Sulphuretted  hydrogen 
and  sulphide  of  ammonium  are  sometimes  found  in  privy- vaults, 
and,  although  they  will  not  extinguish  a  light,  they  speedily 
prove  fatal  if  inhaled  in  a  concentrated  form,  and  to  the  exclu- 
sion of  a  sufficiency  of  oxygen.3  Cases  have  frequently  occurred 
where  serious  or  fatal  results  ensued  from  the  presence  of  a  dan- 
gerous gas,  which  was  thought  to  be  excluded  by  the  burning 
candle. 

1  Recent  observations  in  this  country  (see  Annual  Reports  of  the  Surgeon-General  of 
the  Navy  for  1879.  pp.  45  and  46,  and  the  same  for  1880,  pp.  31  to  34)  seem  to  throw  some  doubt  upon 
the  entire  reliability  of  this  method  of  determining  the  amount  of  organic  matter  in  the  air 
examined.  Trof.  Ira  Remsen  (Report  National  Board  of  Health,  1879,  p.  77,  and  1880,  p.  308  et 
seq.)  has  shown  the  insufficiency  of  the  chemical  methods  at  present  in  use,  and  points  out  the 
difficulties  of  making  trustworthy  and  satisfactory  determinations  of  organic  matter  in  the  air. 
The  great  technical  difficulties  of  the  various  analytical  processes  render  it  unwise  to  burden 
these  pages  with  a  description  of  them.  Only  expert  chemists  are  qualified  to  make  a  thorough 
air  analysis,  and  the  author  does  not  feel  competent  to  offer  advice  to  them.  Dr.  Cornelius  B. 
Pox's  book  on  "  Sanitary  Examinations  of  Water,  Air,  and  Food,"  and  Fliigge's  "Lehrbuch  der 
Hygienischen  Untersuchungsmethoden"  contain  detailed  descriptions  of  the  best  methods 
employed. 

a  Dr.  G.  M.  Sternberg,  U.  8.  A.  (Report  National  Board  of  Health,  1880),  gives  an  ac 
count  of  his  investigations  into  the  suspended  matters  of  the  air.  The  question  is  also  con- 
sidered in  a  practical  manner  by  Surgeons  Kidder  and  Streets,  TJ.  S.  N.,  in  Reports  of  the 
Surgeon-General  of  the  Navy  for  1880  and  1881.  See  also  Bacteria,  Sternberg  and  Magnin, 
2d  ed.,  p.  197. 

»  See  a  case  reported  in  Philadelphia  Medical  Times,  October  21, 1882. 


38  TEXT-BOOK   OF   HYGIENE. 

It  is  advisable  in  all  cases  to  exhaust  the  stagnant  air  in 
old  wells  and  privy-vaults  before  permitting  any  one  to  descend. 
Perhaps  the  feadiest  method  of  exhausting  the  vitiated  air  in 
such  places  would  be  to  lower  heated  stones,  masses  of  hot  iron 
or  pails  of  hot  water,  to  near  the  bottom,  which  produce  a  rare- 
faction of  the  air  and  cause  it  to  ascend.  Its  place  will  then  be 
occupied  by  purer  air  from  without.  The  rarefaction  produced 
by  the  explosion  of  gun-powder  has  also  been  made  use  of  with 
success ;  but  this  has  some  objections,  because  the  combustion 
of  powder  itself  produces  gases  which  are  noxious  if  breathed 
in  large  quantity.  An  animal,  such  as  a  cat  or  dog,  should  be 
first  lowered  into  the  suspected  well  for  fifteen  or  twenty  min- 
utes, in  order  to  determine  whether  the  air  at  the  bottom  is 
capable  of  sustaining  life,  before  permitting  the  workmen  to 
descend.  Similar  precautions  should  be  used  in  old,  long- 
unused  mines  to  prevent  fatal  effects  from  the  so-called  "  choke- 
damp,"  which  is  largely  composed  of  carbon  dioxide. 

PRINCIPLES   OF   VENTILATION. 

During  ordinary  respiration  an  adult  human  being  adds 
900  grammes  =  455,500  cubic  centimetres  (14  cubic  feet)  of 
carbon  dioxide  to,  and  abstracts  744  grammes  =  516,500  cubic 
centimetres  (16  cubic  feet)  of  oxygen  from,  the  atmosphere  in 
twenty-four  hours.  Hence,  if  the  individual  were  confined  in 
an  apartment  where  the  inclosed  air  could  not  be  intermingled 
by  diffusion  with  the  atmosphere  without,  the  proportion  of 
carbon  dioxide  would  soon  become  so  great  that  the  processes 
of  life  could  not  be  sustained,  and  the  individual  would  die. 
This  result  would  be  reached  even  sooner  than  the  point  here 
mentioned,  for  the  organic  matter  exhaled  from  the  lungs  and 
the  surface  of  the  body  would  increase  the  poisonous  condition 
of  the  air  even  more  than  the  carbon  dioxide  given  off.  It  is 
easily  seen,  therefore,  how  important  the  study  of  the  principles 
and  practice  of  ventilation  becomes  in  hygiene.  In  this  chapter 
only  the  principles  underlying  this  subject  can  be  definitely 


PRINCIPLES   OF   VENTILATION.  39 

stated.  Practical  details  will  be  more  fully  given  in  the  chapters 
devoted  to  dwellings,  schools,  hospitals,  etc. 

It  is  generally  accepted  among  sanitarians  that  the  presence 
of  .07  per  cent.  (7  parts  in  10,000)  of  carbon  dioxide  in  the  air 
indicates  the  greatest  amount  of  organic  impurity  (from  respira- 
tion or  combustion)  consistent  with  the  preservation  of  health. 
As  each  individual  gives  off  from  his  lungs,  in  the  process  of 
respiration,  316  cubic  centimetres  of  carbon  dioxide  per  minute, 
the  diffusion  in  the  air  surrounding  him  must  be  sufficiently 
rapid  to  keep  the  air  to  be  breathed  at  the  standard  of  .07  per 
cent,  above  mentioned. 

Adopting  this  as  the  standard  of  maximum  impurity  allow- 
able, 90  cubic  metres  of  fresh  air  per  hour  will  be  needed  for 
each  individual  to  keep  him  supplied  with  pure  air.  This  is  for 
a  person  in  a  state  of  health ;  in  cases  of  disease  a  more  rapid 
change  of  air  will  be  necessary  to  keep  that  surrounding  the 
patient  in  a  state  of  purity. 

Ventilation  is  defined  by  Worcester  as  "  the  replacement 
of  noxious  or  impure  air  in  an  apartment,  mine,  or  inclosed 
space  by  pure,  fresh  air  from  without."  By  Dr.  Parkes  the 
term  is  restricted  to  "  the  removal  or  dilution,  by  a  supply  of 
pure  air,  of  the  pulmonary  and  cutaneous  exhalations  of  men 
and  the  products  of  combustion  of  lights  in  ordinary  dwellings, 
to  which  must  be  added,  in  hospitals,  the  additional  effluvia 
which  proceed  from  the  persons  and  discharges  of  the  sick.  All 
other  causes  of  impurity  of  air  ought  to  be  excluded  by  cleanli- 
ness, proper  removal  of  solid  and  liquid  excreta,  and  attention 
to  the  conditions  surrounding  dwellings." 

A  proper  system  of  ventilation  must  take  into  consideration 
the  cubic  space  of  the  apartment  or  building  to  be  ventilated, 
the  number  of  persons  ordinarily  inhabiting  this  space,  whether 
constantly  or  only  temporarily  occupied,  and  certain  other  col- 
lateral elements,  such  as  the  character  of  the  building  to  be 
ventilated,  its  exposure,  necessity  for  artificial  heating,  etc. 

1  Manual  of  Practical  Hygiene,  6th  ed.,  New  York,  vol.  i,  p.  157. 


40  TEXT-BOOK   OF    HYGIENE. 

The  amount  of  cubic  space  that  must  be  allowed  to  each 
individual  is  determined  by  the  rapidity  with  which  fresh  air 
must  be  supplied  in  order  to  keep  that  surrounding  the  indi- 
vidual at  the  standard  of  less  than  .07  per  cent,  of  carbon  dioxide. 
For  example,  in  a  space  of  3  cubic  metres,  the  air  must  be 
changed  thirty  times  in  an  hour,  in  order  to  prevent  the  carbon 
dioxide  exceeding  the  above  proportion ;  that  is  to  say,  to  allow 
90  cubic  metres  of  air  to  pass  through  that  space  in  the  time 
mentioned.  This  would  create  an  uncomfortable,  if  not  injurious, 
draught.  If  the  space  contained  30  cubic  metres,  the  air  would 
need  renewal  only  three  times  an  hour. 

A  space  of  15  cubic  metres  could  be  kept  supplied  with 
pure  air  without  perceptible  movement  if  all  the  mechanical 
arrangements  for  changing  the  air  were  perfect ;  but  such  per- 
fection is  rarely  attainable,  and  hence  there  would  be  either 
draughts  or  insufficient  ventilation  in  such  a  small  "  initial  air- 
space," as  it  is  termed.  The  initial  air-space  should,  therefore, 
be  not  less  than  30,  or,  better,  40  cubic  metres.  The  air  of  this 
space  could  be  changed  sufficiently  often  to  keep  it  at  its  standard 
of  purity  without  creating  unnecessary  draught.  For  sick  per- 
sons this  should  be  doubled.  In  hospitals,  therefore,  the  cubic 
air-space  allowed  to  each  bed  should  not  be  less  than  60  to  80 
cubic  metres. 

As  stated,  the  purposes  for  which  the  building  or  apartment 
to  be  ventilated  are  employed  require  differences  in  the  cubic 
space  and  in  the  volume  of  fresh  air  supplied.  Morin  gives  the 
following  table : — 


TABLE  III. 

Fresh  Air  Required 
per  Hour  per  Head. 

Hospital  wards  for  ordinary  cases,         .       60-70  cubic  metres. 
Hospital  wards  for  surgical  and  obstet- 
rical cases, 100  "         " 

Hospital  wards  for  contagious  diseases,  150  "         " 

Prisons, 50  "         " 


PRINCIPLES   OF   VENTILATION.  41 

Workshops      |ordinary  occupations,    .  60         cubic  metres. 

(unhealthy,        "'             .  100  "  " 

Barracks,         jduring  the  day,      .         .  30 

(     "          "    night,  .         .  40-50  "  " 

Theatres, 40-50  "  " 

Assembly  rooms  for  long  receptions,     .  60  "  " 

"               "        "    brief        u               .  30  "  " 

Primary  schools, 12-15  "  " 

Higher         " 25-30  "  " 

Stables, 180-200     "  " 

These  figures  are  not  excessive  from  a  sanitary  stand-point, 
although  few  buildings  meet  the  requirements  here  set  down. 

The  source  of  the  air  supplied  must,  o*f  course,  be  capable 
of  yielding  pure  air.  It  should  not  be  drawn  from  damp  cellars 
or  basements,  or  from  the  immediate  vicinity  of  sewers  or  drains. 
Air  taken  from  such  places  is  little  better  for  respiration  than 
that  which  it  replaces  in  the  apartments  to  be  ventilated. 

Ventilation  may  be  accomplished  either  with  or  without 
artificial  aids.  In  buildings  or  rooms,  used  as  habitations, 
natural  ventilation  (with,  perhaps,  the  simplest  mechanical  aids) 
is  made  use  of  almost  entirely.  In  large  buildings,  such  as 
churches,  theatres,  schools,  or  in  ships  and  mines,  one  of  the 
artificial  systems  must  be  adopted  if  efficient  ventilation  is 
desired. 

Natural  ventilation  takes  place  by  diffusion,  by  perflation, 
and  in  consequence  of  inequality  of  atmospheric  pressure.  By 
diffusion  is  meant  the  slow  and  equable  entrance  of  air  from 
without  and  exit  from  within  a  room  through  the  walls  or  ill- 
made  joints  without  the  influence  of  wind-currents.  In  an 
occupied  room  this  is,  however,  insufficient  to  keep  the  air  pure, 
because  many  of  the  organic  impurities  of  respired  air  are  mole- 
cular, and,  therefore,  incapable  of  making  their  way  out  of  the 
rooms  through  the  walls. 

Perflation  means,  literally,  "  blowing  through,"  and,  if  the 
direction  and  force  of  air-currents  could  be  regulated,  this  would, 
with  simple  mechanical  arrangements,  be  an  efficient  means  of 


42  TEXT-BOOK   OF   HYGIENE. 

ventilation.  However,  the  uncertainty  of  the  force  and  direc- 
tion of  the  wind  makes  this  method  of  ventilation  untrustworthy, 
except  in  warm  weather. 

Unequal  pressure  between  the  air  in  a  room  and  that 
without  is,  within  certain  limits,  an  efficient  means  of  ventila- 
tion, and  is  usually  relied  upon  in  ordinary  apartments.  When 
the  air  in  a  room  is  heated  above  the  temperature  of  the  external 
air,  either  by  a  fire,  lights,  or  by  the  presence  of  a  number  of 
persons  in  the  room,  it  expands,  and  part  of  it  finds  its  way  out 
through  numerous  crevices  and  bad  joints  found  in  all  buildings. 
The  air  which  remains,  being  less  dense  than  the  external  air, 
the  latter  enters  the  room  by  various  openings,  until  the  equality 
of  pressure  is  re-established.  But  as  the  heating  of  the  enclosed 
air  continues,  the  process  is  momentarily  repeated  and  becomes 
continuous. 

Although  the  impurities  of  respired  air  (carbon  dioxide, 
organic  matter)  are  heavier  than  the  air  itself  at  the  same 
temperature,  it  is  a  familiar  fact  that  the  most  impure  air  in  an 
occupied  room  is  always  found  near  the  ceiling,  the  impurities 
being  carried  upward  with  the  heated  air,  and  that  the  pure  air 
from  without,  being  colder,  fills  the  lower  part  of  the  room. 

If  the  cold,  outside  air  were  to  be  admitted  at  the  bottom 
of  the  room,  and  means  allowed  for  the  escape  of  the  hot  air  at 
the  top,  the  conditions  of  the  old  health-maxim,  to  "  keep  the 
feet  warm  and  the  head  cool,"  would  be  reversed,  This  would 
be  no  less  uncomfortable  than  unwholesome.  In  all  plans  for 
natural  ventilation,  therefore,  provision  must  be  made  to  secure 
a  gradual  diffusion  of  the  cold,  outside  air  from  above,  or  to 
have  it  warmed  before  it  enters  the  room.  With  a  large  chimney 
as  an  aspirating  shaft,1  with  flues  at  the  top  and  bottom  of  the 
room,  and  openings  in  the  walls  of  the  room  near  the  ceiling  to 
admit  fresh  air,  sufficient  ventilation  can  be  usually  secured  in 
cold  weather,  in  a  room  not  overcrowded. 

1  Of  course  there  is  really  no  such  thing  as  a  real  aspiration,  or  "sucking  out"  of  the  air 
through  the  chimney  or  so-called  "aspirating  shaft."  The  upward  movement  of  the  air  in  the 
shaft  is  due  to  its  displacement  by  the  colder  or  denser  air  entering  the  room. 


PRINCIPLES   OF   VENTILATION.  43 

When  a  room  is  heated  by  a  furnace,  the  fresh  air  is  warmed 
before  it  is  introduced,  and  the  foul  air  escapes  either  through  a 
ventilating  shaft,  a  ventilator  in  the  window  or  wall,  or  through 
the  numerous  fissures  and  other  orifices  which  defective  car- 
pentering always  leaves  for  the  benefit  of  the  health  of  the 
occupants. 

The  following  rules  for  the  arrangement  of  a  system  of 
natural  ventilation  are  modified  and  condensed  from  Parkes1: — 

The  apertures  of  entrance  and  of  exit  for  the  air  should  be 
placed  far  enough  apart  to  permit  thorough  diffusion  of  the 
fresh  air. 

When  the  air  is  brought  into  a  room  through  slits  or  tubes 
in  the  walls  near  the  ceiling,  the  current  should  always  be 
deflected  upward  by  an  inclined  plane,  in  order  to  prevent  a 
mass  of  cold  air  from  descending  over  the  shoulders  of  the 
occupants  and  chilling  them. 

The  air  must  be  taken  from  a  pure  source. 

The  inlet-tubes  should  be  short,  and  so  made  as  to  be  easily 
cleansed,  otherwise  dirt  lodges  and  the  air  becomes  impure. 

Inlets  should  be  numerous  and  small,  to  allow  a  proper 
distribution  of  the  entering  air. 

Externally,  the  inlets  should  be  partially  protected  from 
the  wind  to  prevent  strong  draughts ;  they  should  also  be  pro- 
vided with  valves  to  regulate  the  supply  of  air. 

If  the  air  cannot  be  warmed,  the  inlets  must  be  near  the 
ceiling ;  if  it  can  be  heated,  it  may  enter  near  the  floor. 

The  air  may  be  warmed  by  passing  it  through  boxes  con- 
taining hot  water  or  steam  coils,  by  passing  it  through  chambers 
around  grates  or  stoves,  or  heating  it  in  a  furnace. 

In  towns  or  manufacturing  districts  the  air  should  be 
filtered  before  allowing  it  to  enter  the  room.  Thin  flannel  or 
muslin  spread  over  the  openings  answers  very  well  as  filtering 
material. 

Outlets  should  be  placed  at  the  highest  point  of  the  room 

1  Manual  of  Practical  Hygiene,  6th  ed.,  New  York,  vol.  i,  p.  177. 


44  TEXT-BOOK   OF   HYGIENE. 

and  should  be  protected  from  the  weather.    An  opening  into  the 
chimney  near  the  ceiling  will  answer  well  in  many  cases. 

In  one-story  buildings,  ridge-ventilators  make  the  best  out- 
lets. The  entrance  of  snow  and  rain  must  be  prevented  by 
suitable  arrangements. 

A  small  space  or  slit  between  the  horizontal  bars  of  the 
upper  and  lower  window-sash  will  admit  sufficient  air  in  a  proper 
direction  in  small  rooms,  even  when  the  window  is  shut. 

In  all  rooms,  howsoever  ventilated,  doors  and  windows 
should  be  often  opened  to  permit  a  thorough  flushing  of  the 
interior  with  fresh  air. 

For  large  buildings,  hospitals,  schools,  theatres,  ships,  and 
mines  two  systems  of  artificial  ventilation  are  in  use.  One 
operates  by  extracting  the  foul  air  by  means  of  fans,  the  other 
by  forcing  in  fresh  air,  allowing  the  impure  air  to  find  its  way 
out  as  best  it  may. 

Rotating  cowls  on  the  tops  of  chimneys  may  be  used  to 
increase  the  aspirating  power  of  the  air ;  in  this  way  the 
natural  force  of  the  wind  may  be  utilized  for  ventilation  of 
rooms  or  buildings  of  moderate  size. 

Further  details  upon  the  practical  application  of  these  prin- 
ciples will  be  given  in  succeeding  chapters  of  this  work. 

[In  addition  to  the  works  mentioned  in  the  text  the  follow- 
ing may  be  referred  to  as  more  fully  treating  of  the  subjects 
considered  in  this  chapter : — 

Flammarion  :  The  Atmosphere. — The  Articles  on  Atmosphere  and 
Climate  in  the  Encyclopaedia  Britannica,  9th  edition. — Reports  of  the 
Chief  Signal  Officer  of  the  Army. — A  paper  on  Climate  and  Diseases,  by 
Dr.  Cleveland  Abbe,  in  Report  of  National  Board  of  Health  for  1880.— 
Die  Canalgase,  by  Dr.  F.  Renk,  Mnnchen,  1884. — Morin  :  On  Warming 
and  Ventilating  Occupied  Buildings ;  translated  in  Smithsonian  Report 
for  1873  and  1874. — Y.  Pettenkofer  und  Ziemssen's  Handbuch  der  Hy- 
giene, I  Theil,  2  Abtheilung.  Die  Luft,  by  Dr.  F.  Renk.— A.  Woeikof:- 
Die  Klimate  der  Erde,  1887. — B.  W.  James:  American  Resorts,  1889. — 
A.  W.  Greely  :  American  Weather,  1888. — Jules  Rochard  :  Questions 
d'Hygiene  Sociale ;  L'Acelimatement  dans  les  Colonies  Fran9aises, 
1891.— Kenwood  :  The  Hygienic  Laboratory,  Part  III,  1893.] 


QUESTIONS   TO   CHAPTER   I. 

AIR. 

What  is  the  composition  of  the  atmospheric  air  ?  Is  the  mixture  a 
chemical  or  mechanical  one  ?  What  constituent  is  the  most  constant  in 
proportion,  and  what  ones  most  variable?  What  are  the  causes  and 
limits  of  variation  in  the  composition  of  the  air  ?  Has  this  variation  any 
effect  upon  health  ? 

How  is  the  general  uniformity  of  composition  maintained?  What 
is  the  relation  of  the  oxygen  and  carbon  dioxide  to  plant  and  animal  life 
and  to  one  another  ? 

What  is  the  depth  of  the  atmosphere  ?  What  is  its  weight,  and  how 
is  this  measured  ?  How  may  you  determine  the  altitude  of  any  place 
above  the  sea-level  ? 

What  effect  has  temperature  on  barometric  pressure  ?  What  effect 
has  moisture,  and  why?  Whence  does  the  air  derive  its  warmth? 
Where  is  the  atmosphere  warmest  ? 

What  is  the  relation  between  the  temperature  and  humidity  of  the 
air  ?  What  is  meant  by  "  absolute  "  and  "  relative  "  humidity  ?  How  is 
each  always  designated  ?  What  is  meant  by  "  saturation  "? 

What  causes  motion  in  air  or  wind?  What  conditions  of  the  atmos- 
phere probably  have  relation  to,  or  influence  upon,  disease  ?  Why  should 
a  sanitarian  be  a  practical  meteorologist? 

What  are  the  physiological  effects  of  diminution  of  atmospheric 
pressure  ?  What  may  aggravate  these  effects  ?  To  what  are  they  due  ? 
Can  the  human  body  become  accustomed  to  them?  What  name  is  given 
to  this  pli3Tsiological  disturbance  ?  What  diseases  will  probably  improve 
in  a  rarefied  atmosphere,  and  what  ones  will  not  ? 

What  are  the  effects  of  increased  atmospheric  pressure  upon  the 
organism  ?  Is  there  any  danger  of  fatal  results  ?  Have  the  diurnal 
variations  of  pressure  any  effect  upon  the  body  in  health  or  in  disease? 

What  effect  has  high  temperature  upon  health  ?  What  diseases  are 
more  frequent  in  hot  weather  and  in  hot  climates  ? 

What  peculiar  affection  seems  to  be  caused  or  favored  by  long- 
continued  exposure  to  cold?  What  are  some  of  the  acute  effects  of 

(45) 


46  QUESTIONS   TO   CHAPTER   I. 

cold?  What  effect  has  the  relative  humidity  in  the  production  of  these 
diseases?  Indicate  and  explain  a  possible  relationship  of  causation 
between  coryza  or  influenza,  bronchitis  and  pneumonia.  Is  this  altogether 
substantiated  by  statistics  ?  Is  low  temperature  the  only  cause  of  pneu- 
monia ? 

What  part  has  the  relative  humidity  in  the  production  of  certain 
diseases  ? 

What  is  the  general  rule  as  to  the  effect  of  winds  or  air-currents 
upon  health  ?  Name  some  apparent  exceptions  to  this  rule.  Has  the 
season  an}rthing  to  do  with  the  morbidity  and  mortality  from  different 
diseases  ?  Give  examples. 

What  is  the  average  proportion  of  carbon  dioxide  in  the  atmos- 
phere ?  What  should  be  the  maximum  limit  permissible  in  dwellings  ? 
Is  this  limit  often  exceeded  ?  When  exceeded,  to  what  are  the  evil 
effects  upon  health  probably  due?  How  much  carbon  dioxide  alone 
may  be  present  in  the  atmosphere  without  producing  any  apparent 
ill  effects  ? 

When  and  where  in  the  out-door  atmosphere  is  the  proportion  of 
carbon  dioxide  greatest  ?  In  what  way  may  this  be  explained  ? 

What  are  the  products  of  respiration  and  perspiration,  and  which 
of  these  is  most  harmful  to  health  ?  What  evidence  have  we  to  that 
effect?  Have  we  any  evidence  that  the  respiratory  carbon  dioxide 
alone  is  harmful  to  health  ?  Where  there  is  a  moderate  degree  of  re- 
spiratory pollution,  what  are  some  of  the  symptoms  usually  produced 
thereby  ?  In  the  production  of  what  especial  disease  has  impure  air  a 
decidedly  causative  influence? 

Which  is  the  more  dangerous  to  health,  carbon  monoxide  or  carbon 
dioxide?  Of  what  gases  is  the  former  an  ingredient?  How  does  it 
produce  its  harmful  effects? 

Have  sulphuretted  and  carbnretted  hydrogen  any  effect  upon  health? 
If  so,  in  what  proportions  must  they  be  in  the  atmosphere  ?  Has  ammo- 
nia, in  the  proportion  in  which  it  is  usually  found  in  the  atmosphere,  any 
bad  effect  upon  health  ? 

What  is  sewer-air'  or  sewer-gas,  and  what  are  some  of  its  constit- 
uents ?  In  what  way  may  it  be  the  cause  of  infectious  disease  ?  Will 
the  continued  breathing  of  air  polluted  with  sewer-gas  affect  health,  and, 
if  so,  what  symptoms  may  be  caused  thereby  ?  What  must  be  necessarily 
present  in  the  sewer-gas  for  it  to  be  a  cause  of  typhoid  fever? 

Is  there  any  positive  evidence  that  the  emanations  from  cemeteries, 
bone-yards,  etc.,  are  harmful  to  health  ? 


QUESTIONS   TO   CHAPTER   I.  47 

What  diseases  may  be  produced  by  the  inhalation  of  pathogenic 
micro-organisms  carried  by  the  air  ? 

What  tests  have  we  for  the  various  impurities  in  the  air  ?  What 
reagents  may  be  used  to  determine  the  presence  and  amount  of  carbon 
dioxide  in  the  atmosphere  ?  Describe  briefly  the  Angus  Smith  minimet- 
ric  test  and  Wolpert's  air-tester.  What  precautions  must  be  observed 
with  the  latter?  Wherein  may  each  be  improved?  (See  chapter  oil 
"  Examination  of  Air,  Water,  and  Food,"  page  413.) 

What  reagent  is  used  to  detect  carbon  monoxide  ?  Can  the  amount 
of  respiratory  organic  matter  in  air  be  readily  determined  directly  ? 
What  discovery  did  Pettenkofer  and  de  Chaumont  make  regarding  the 
relation  between  the  respiratory  organic  matter  and  carbon  dioxide  in 
the  air? 

How  may  the  presence  of  quantities  of  carbon  dioxide  sufficient  to 
endanger  life  be  determined  in  wells  or  cess-pools,  and  how  may  such 
quantities  of  this  gas  be  removed  ?  What  other  gases  dangerous  to  life 
might  be  present  in  cess-pools  and  yet  not  be  indicated  by  the  above  test  ? 

Ventilation. — How  much  oxygen  does  an  adult  human  being  at  rest 
ordinarity  take  from  the  air,  and  how  much  carbon  dioxide  does  he  add 
to  it  in  twenty -four  hours  ?  What  percentage  of  carbon  dioxide  in  the 
air  indicates  the  greatest  amount  of  organic  impurity  from  respiration, 
etc.,  consistent  with  health?  How  much  fresh  air  per  hour  is,  therefore, 
needed  by  each  individual  to  maintain  this  state  of  purity  ?  Will  sick 
persons  need  more  fresh  air  than  the  well  ?  Why  ? 

What  is  meant  by  ventilation?  What  should  be  excluded  from  the 
term? 

What  matters  must  a  proper  system  of  ventilation  consider?  What 
governs  the  amount  of  cubic  space  that  can  be  allotted  to  each  individual  ? 
What  should  be  the  minimum  air-space  for  the  well,  and  what  for  the 
sick?  What  should  be  the  floor-space  for  each  person,  and  why  ?  From 
what  kind  of  a  source  must  the  air  for  a  ventilation  supply  be  taken  ? 

What  is  the  difference  between  natural  and  artificial  ventilation  ? 
What  are  the  forces  acting  to  produce  natural  ventilation  ?  What  is 
meant  by  diffusion  ?  Why  is  it  insufficient  for  ventilating  an  occupied 
room?  What  is  meant  by  perflation?  Why  cannot  it  be  used  alone 
for  ventilation?  Upon  what  does  the  inequality  of  atmospheric  pressure 
depend  ?  Why  is  it  the  most  valuable  of  the  forces  of  natural  ventilation  ? 

In  what  part  of  an  occupied  room  is  the  most  impure  air  found, 
and  why  ? 

What  precautions  must  be  observed  in  all  plans  for  natural  ventila- 


48  QUESTIONS   TO   CHAPTER   I. 

tion  ?  What  makes  the  air  from  a  room  pass  up  a  chimney  ?  When  a 
room  is  heated  by  a  hot-air  furnace,  how  does  the  foul  or  used  air  escape? 
What  rules  may  be  laid  down  for  the  arrangement  of  a  system  of  natural 
ventilation  ? 

Where  should  the  fresh-air  inlets  of  a  room  be  located  ?  How  may 
the  air  be  warmed  before  bringing  it  into  the  room  ?  How  should  the 
inlet-tubes  be  arranged  ?  Where  should  the  outlets  of  a  room  be  located  ? 

What  systems  of  artificial  ventilation  may  be  employed  for  large 
buildings  or  rooms  ?  By  what  appliances  may  we  make  use  of  winds  for 
ventilating  purposes  ? 


CHAPTER  II. 

WATER. 

PHYSIOLOGISTS  teach  that  nearly  two-thirds  of  the  tissue  of 
the  animal  body  consists  of  water.  Inasmuch  as  this  water  is 
constantly  being  lost  by  evaporation  from  the  skin,  exhalation 
by  the  lungs,  and  excretion  through  various  organs,  it  is  evident 
that  the  loss  must  be  constantly  supplied  if  the  functions  of  life 
shall  be  properly  performed. 

It  appears  probable  that  certain  diseases  are  at  times  spread 
through  the  agency  of  insufficient  or  impure  drinking-water. 
It  is,  therefore,  a  matter  of  very  great  importance  to  have  a  defi- 
nite notion  of  what  constitutes  a  pure  and  sufficient  supply  of 
water,  and  how  best  to  secure  it,  to  be  able  to  detect  its  condi- 
tions of  purity  and  impurity,  and  to  know  how  to  maintain  the 
former  and  avoid  the  latter.  It  will  be  necessary  to  consider  in 
detail,  therefore,  the  quantity  of  water  required  by  each  indi- 
vidual for  the  maintenance  of  health,  the  sources  whence  water 
is  obtained,  how  it  should  be  collected  and  stored  to  the  best 
advantage,  the  impurities  likely  to  be  contained  in  it,  and  the 
methods  of  keeping  it  pure,  or  of  purifying  it  when  it  has 
become  polluted  or  vitiated  in  any  manner. 

THE   QUANTITY   OF   WATER    REQUIRED   BY   HUMAN   BEINGS. 

Dr.  Parkes,  after  a  number  of  experiments,  concluded  that 
a  man  of  the  English  middle  class,  "who  may  be  taken  as  a 
fair  type  of  a  cleanly  man  belonging  to  a  fairly  cleanly  house- 
hold," uses  about  twelve  gallons  of  water  per  day.  This  covers 
all  the  water  needed,  including  a  daily  sponge  bath.  Dr. 
DeChaumont  estimates1  that  16  gallons  should  be  the  daily 

1  Parkes'  Hygiene,  6th  ed.,  New  York,  vol.  i,  p.  5. 

(49) 


50  TEXT-BOOK   OF   HYGIENE. 

allowance.  By  order  of  the  British  War  Department,  15  gal- 
lons of  water  are  allowed  to  each  soldier  daily.  In  very  many 
instances  this  quantity  cannot  be  furnished,  but  in  such  cases 
there  necessarily  results  some  deficiency  in  cleanliness.  It  is 
probable  that  among  the  poorer  classes,  especially  where  a  large 
supply  of  water  is  not  convenient,  the  quantity  used  is  not  over 
one-fourth  of  the  above  estimate. 

In  estimating  the  daily  supply  of  water  needed  in  a  com- 
munity, large  or  small,  other  circumstances  must  be  taken  into 
consideration  in  addition  to  the  demands  of  the  individual. 
For  example,  in  towns  or  cities  allowances  must  be  made  for 
animals,  manufacturing  purposes,  probable  waste,  fires,  sewerage, 
etc.  In  cities  an  allowance  of  50  gallons  daily  per  head  would 
not  be  excessive.  In  most  American  cities  the  supply  is  much 
greater.1  The  present  daily  supply  in  Baltimore,  which  is  de- 
rived from  an  excellent  source,  is  estimated  at  60  gallons  per 
head,  which  could  be  increased  to  three  times  that  quantity  if 
necessary. 

A  serious  problem,  affecting,  however,  the  engineer  rather 
than  the  sanitarian,  is  the  prevention  of  waste  of  water  in  places 
where  the  supply  is  limited.  It  is  estimated  that  in  Chicago 
one-half  of  the  water  pumped  is  wasted  through  negligence  and 
imperfections  in  the  supply  apparatus,  while  in  St.  Louis  the 
annual  cost  to  the  city  of  the  water  that  is  wasted  is  placed  at 
$400,000.  It  has  been  proposed  to  check  this  wanton  waste  by 
measuring  the  quantity  of  water  used  by  each  household  by 
means  of  a  meter,  as  the  supply  of  gas  is  now  measured,  and 
this  has  been  carried  into  effect  in  places.  There  are,  however, 
serious  objections  to  this  method.  One  of  the  objections  is  that 
the  very  class  of  persons  whom  it  is  desired  to  induce  to  use  a 
plentiful  supply  of  water  would,  from  motives  of  economy,  use 
less  than  is  necessary  for  cleanliness  and  health.  A  system  of 
vigilant  inspection  of  the  water  service  in  houses  would  probably 
serve  to  reduce  this  unnecessary  waste  to  a  considerable  extent. 

1  Buck's  Hygiene  and  Public  Health,  voL  i,  p.  214. 


SOURCES   OF   DRINKING-WATER.  51 

SOURCES   OF   DRINKING-WATER. 

All  water,  from  whatever  direct  source  obtained,  comes 
originally,  by  precipitation,  from  the  atmosphere.  In  many 
places  the  rain-  or  snow-  water  is  the  only  source  of  supply.  This 
is  usually  collected  as  it  falls  upon  the  roofs  of  buildings  and 
conveyed  by  gutters  and  pipes  to  cisterns,  where  it  is  stored  until 
needed. 

In  Venice,  the  rain  falling  upon  the  streets  and  court- 
yards is  also  collected  in  cisterns  after  filtering  through  sand. 
The  cisterns  used  for  the  storage  of  water  in  New  Orleans  and 
other  Southern  cities  in  the  United  States,  where  the  tempera- 
ture rarely  falls  below  the  freezing-point,  are  generally  con- 
structed of  wood  and  placed  above-ground.  Farther  north, 
where  it  is  necessary  to  protect  them  against  the  action  of  frost, 
they  are  placed  under-ground.  These  under-ground  cisterns  are 
usually  built  of  brick.  The  water  from  cisterns  above-ground 
becomes  very  much  heated  in  summer,  and  necessitates  the  use 
of  large  quantities  of  ice  to  make  it  palatable.  The  water  from 
the  under-ground  cisterns  is  pleasantly  cool  in  summer,  and  is 
also  guarded  against  freezing  in  winter,  There  are,  however, 
very  serious  objections  to  storing  drinking-water  in  under-ground 
cisterns.  These  reservoirs  are  usually  placed  within  a  few  feet 
of  privies  and  cess-pools,  and,  as  neither  the  retaining  walls  of 
the  cisterns  nor  those  of  the  privies  are  water-tight,  it  often 
happens  that  the  drinking-water  becomes  strongly  impregnated 
with  the  soluble  portions  of  the  excrement,  or  the  products  of 
its  decomposition,  which  have  drained  into  the  cistern.  Per- 
sonal observations  in  Memphis  in  1879,  as  well  as  the  careful 
chemical  analyses  made  afterward  by  Dr.  Chas.  Smart,  U.  S.  A.,1 
have  convinced  the  author  that  the  objections  to  all  under- 
ground cisterns  built  of  brick,  stone,  or  cement  are  insuperable 
from  a  sanitary  point  of  view.  Dr.  Smart  found  over  one-half 
of  the  under-ground  cisterns  examined  by  him  in  Memphis  and 

1  Report  National  Hoard  of  Health,  1880,  pp.  437-441. 


52  TEXT-BOOK   OF    HYGIENE. 

other  cities  and  towns  to  be  leaky  and  presenting  evidence  of 
organic  pollution.  The  water  from  31  out  of  80  cisterns  ana- 
lyzed showed  decided  contamination  by  sewage.  It  would  seem 
advisable  to  prohibit  all  under-ground  cisterns  for  the  storage  of 
drinking-water  unless  they  are  constructed  of  iron,  which  should 
be  protected  against  oxidation  by  a  thorough  coating  of  coal- 
tar.  Where  any  other  system  of  collection  and  storage  is  avail- 
able, however,  the  under-ground  cistern  should  be  unreservedly 
condemned. 

Rain-water  collected  in  the  country,  away  from  manufac- 
turing districts,  is  usually  quite  pure  and  wholesome.  Its  taste 
is,  however,  flat  and  insipid,  owing  to  absence  of  carbon  dioxide 
and  mineral  constituents.  In  cities  rain-water  frequently  con- 
tains such  a  large  amount  of  organic  matter  and  other  impurities, 
which  have  been  washed  out  of  the  air  by  the  rain,  that  it  may 
be  unfit  for  drinking.  On  account  of  its  softness,  rain-water  is 
very  desirable  for  washing  and  other  domestic  purposes.  If  the 
statement  made  in  the  last  chapter,  concerning  the  presence  of 
organisms  in  the  atmosphere,  is  remembered,  it  will  be  evident 
on  a  moment's  thought  that  such  organisms,  when  contained  in 
rain-water,  may  be  the  source  of  disease.  The  putrefaction 
which  so  readily  takes  place  in  rain-water  upon  standing  a  few 
days  is  caused  by  certain  of  the  organisms  carried  down  out  of 
the  lower  strata  of  the  air  by  the  descending  rain  or  snow. 

Precipitation  is  an  exceedingly  untrustworthy  source  of 
water,  and  should  never  be  depended  upon  when  other  sources 
of  supply  are  available.  Water  famines  are  frequent  wherever 
people  are  compelled  to  rely  upon  such  an  uncertain  source  of 
supply  as  rain  or  snow. 

Rivers  and  smaller  streams  probably  supply  the  larger 
number  of  cities  and  towns  in  this  country  with  drinking-water. 
When  care  is  taken  to  prevent  the  pollution  of  the  stream  above 
the  point  whence  the  water  is  taken,  this  is  usually  of  fair 
quality  for  domestic  purposes.  When  the  river  can  be  tapped 
near  its  source,  or  before  a  large  number  of  manufacturing 


SOURCES   OF   DRINKING-WATER.  53 

establishments  can  empty  their  waste  products  into  its  current, 
or  before  it  receives  the  sewage  of  a  considerable  number  of 
inhabitants  living  on  its  banks,  the  water  can  generally  be  re- 
garded as  safe.  It  is  very  difficult,  however,  except  in  the  less 
settled  portions  of  the  country,  to  find  these  favorable  conditions 
present. 

Among  the  minor  objections  to  the  use  of  river- water  for 
domestic  purposes  are  the  liability  of  most '  streams  to  become 
turbid  in  times  of  freshet,  and  the  discoloration  of  the  water 
from  dissolved  coloring-matters  if  the  stream  flows  through  a 
marshy  or  peaty  region.  These  objections  are,  however,  not 
serious,  as  nitration  will  readily  remove  the  suspended  matters. 
The  coloring-matter  is  probably  harmless.  The  organic  matter 
contained  in  the  water  of  some  streams,  even  when  pollution  by 
sewage  and  manufacturing  refuse  is  absolutely  excluded,  may, 
however,  be  the  cause  of  disease.  Dr.  Smart  has  shown1  that 
the  water  from  streams  in  Nebraska,  Wyoming,  and  Utah  con- 
tained organic  matter  varying  in  amount  from  .16  to  .28  parts 
per  million.2  He  thinks  the  so-called  "mountain  fever"  of  the 
Rocky  Mountain  region  is  a  malarial  fever  caused  by  the  large 
amount  of  organic  matter  in  the  drinking-water. 

Dr.  G.  M.  Kober,  U.  S.  A.,  states  that  he  has  frequently 
drunk  water  from  mountain  streams  which  had  a  perceptible 
taste  of  cattle-manure,  and  suggests  that  as  the  origin  of  the 
ammonia  found  by  Dr.  Smart  in  the  water  of  mountain  streams. 
Dr.  Kober  also  regards  the  "mountain  fever"  as  a  typhoid  fever 
with  malarial  complications.3 

The  most  serious  objection  to  the  use  of  river-water  for 
domestic  purposes  is  the  employment  of  streams  as  carriers  of 
refuse  from  manufacturing  establishments,  or  of  the  sewage  of 
cities  and  towns.  In  Great  Britain  and  some  parts  of  the  con- 
tinent of  Europe,  owing  to  the  density  of  population  and  the 

1  American  Journal  Med.  Sciences,  January,  1878,  p.  28  et  seq. 

*  The  source  of  this  organic  matter  seems  to  be  the  melted  snow  which  makes  up  a  large 
portion  of  the  streams. 

3  Report  of  California  State  Board  of  Health  for  1886,  pp.  48  and  177. 


54  TEXT-BOOK   OF   HYGIENE. 

variety  and  extent  of  manufacturing  industries,  many  of  the 
streams  are  in  an  extremely  filthy  condition.  In  this  country, 
too,  especially  in  the  more  thickly  settled  manufacturing  districts 
of  New  England,  the  pollution  of  rivers  has  increased  to  a 
degree  to  seriously  jeopardize  the  health  of  the  people  who  are 
compelled  to  draw  their  water-supply  from  such  streams.  Several 
years  since  a  commission  was  appointed  by  the  State  Board  of 
Health  of  Massachusetts  to  inquire  into  the  extent  of  the  pollu- 
tion of  the  streams  in  that  State,  and  to  devise  means  for  pre- 
venting such  pollution.  The  commission  extended  its  inquiries 
and  observations  over  several  years,  reporting  the  result  to  the 
State  authorities  at  intervals.1  It  was  found  that  the  water  of  the 
Blackstone  River,  at  Blackstone,  where  it  crosses  the  State  line 
and  enters  Rhode  Island,  contained  over  10  per  cent,  of  sewage 
and  refuse  waters.2  Other  streams  in  Massachusetts  show 
similar  pollution.  That  the  presence  of  such  excessive  con- 
tamination renders  the  water  unsuitable  for  domestic  pur- 
poses must  appear  evident.  It  is  probable,  however,  that  the 
most  dangerous  of  the  polluting  matters  are  the  excreta  of 
human  beings,  especially  those  of  patients  suffering  from  certain 
specific  diseases,  such  as  typhoid  fever  or  cholera. 

Only  a  few  years  ago  it  was  a  generally-accepted  theory 
that  running-water,  though  polluted  by  sewage,  "purifies  itself" 
after  flowing  a  distance  of  twelve  miles,  and  the  comforting  and 
reassuring  doctrine  is  still  held  by  many.  Recent  observations 
point  to  the  conclusion,  however,  that  the  self-purification  of 
rivers  is  not  entirely  to  be  relied  upon.  A  certain  proportion 
of  the  sewage,  it  is  true,  undergoes  oxidation  in  the  presence  of 
light  and  air  and  minute  organisms,3  and  so  becomes  changed 
into  other,  possibly  innocuous  compounds.  But  at  present  it  is 
not  known  what  proportion  or  what  kind  of  organic  matter 
does  undergo  this  change.  Another  portion  of  the  impurities 
is  deposited  upon  the  bottom  and  sides  of  the  stream,  having 

1  Reports  State  Hoard  of  Health  of  Massachusetts  for  1873,  1874,  1876,  1877,  1878,  1879, 1880. 

1  Report  State  Hoard  of  Health  of  Massachusetts,  1876,  p.  145. 

1  Desinfection,  in  Eulenburg's  Realencyclopaedie  d.  ges.  Heilkunde,  vol.  iv,  p.  68. 


SOURCES   OF   DRINKING-WATER.  55 

been  only  held  in  suspension,  and  not  dissolved  in  the  water.  A 
portion  probably  forms  chemical  combinations  with  other  sus- 
pended or  dissolved  matters,  and  is  changed  into  compounds 
which  may  be  volatile  and  pass  off  into  the  air,  or  form  insoluble 
precipitates. 

The  remainder  is  rendered  less  perceptible  or  imperceptible 
to  chemical  means  by  dilution.  Every  stream  has  sources  of 
inflowing  water — feeders — which  increase  its  volume,  and  thus 
dilute  any  foreign  admixture. 

In  view  of  these  facts,  the  theory  of  the  self-purification 
of  streams,  as  formerly  held,  can  no  longer  be  regarded  as  true. 
But  it  is  unquestionably  true  that  running-water  does  regain  its 
purity  if  the  inflow  of  sewage  and  other  refuse  is  not  excessive. 
It  cannot  be  stated  with  confidence,  however,  when  a  stream, 
once  polluted,  becomes  fit  to  use  again.  Moreover,  as  it  is  not 
possible,  by  any  practicable  chemical  treatment  or  filtration  on 
a  large  scale,  to  make  a  polluted  water  absolutely  wholesome,  it 
is  safer  not  to  use  as  a  source  of  domestic  supply  a  stream  which 
is  known  to  have  been  seriously  contaminated  by  sewage  matters 
or  other  impurities. 

The  water  from  fresh- water  lakes  and  ponds  is  generally  to 
be  preferred  to  river-water  for  domestic  use.  It  is  less  liable  to 
become  turbid  from  time  to  time,  and,  except  in  the  case  of 
small  ponds,  inflow  of  sewage  is  not  likely  to  cause  fouling  of 
the  water  to  any  serious  extent.  When  the  supply  can  be 
drawn  from  large  lakes,  as  is  done  in  Chicago  and  other  cities 
on  the  great  lakes  of  the  United  States,  no  purer  or  better  source 
can  be  desired.  In  these  cases  the  point  whence  the  water  is 
taken  should  be  far  enough  from  shore  to  avoid  possibility  of 
sewage  contamination.  When  the  water-supply  is  taken  from 
small  ponds,  all  sewage  and  waste  products  from  houses  and 
factories  must  be  rigidly  excluded ;  otherwise,  diseases  attribu- 
table to  the  polluted  water  are  likely  to  arise  among  those  using 
the  same. 

The  water  in  small  lakes  and  storage  reservoirs  sometimes 


56  TEXT-BOOK   OP   HYGIENE. 

becomes  offensive  in  taste  and  odor.  The  water-supplies  of 
several  of  the  large  Eastern  cities  have  within  the  past  seven  or 
eight  years  at  times  had  a  peculiar  odor  and  taste  somewhat 
resembling  cucumbers.  After  considerable  study,  Prof.  Ira 
Remsen,  of  Baltimore,  found  the  cause  of  this  odor  and  taste 
in  a  minute  fresh- water  sponge,  the  Spongilla  fluviatilis.  A  still 
more  offensive  odor,  tersely  described  as  the  "  pig-pen  odor,"  is 
given  to  the  water  by  the  decay  of  certain  species  of  nostoc  and 
other  algae.  It  is  not  known  that  either  these  vegetable  or 
animal  organisms,  if  present,  render  the  water  prejudicial  to 
health. 

Ponds  are  often  used  as  sources  of  ice-supply.  It  was 
formerly  supposed  that  in  the  process  of  freezing,  solid  matters 
in  the  water  were  not  included  in  the  block  of  ice  when  con- 
gelation occurred.  Recent  observations  have  shown  the  falsity 
of  this  assumption.  In  1875,  an  outbreak  of  acute  intestinal 
disease  at  Rye  Beach,  New  Hampshire,  led  to  an  inquiry  by 
Dr.  A.  H.  Nichols,  which  disclosed  the  fact  that  the  ice  used 
contained  a  large  percentage  of  organic  matter.1  The  use  of 
ice  from  a  different  source  was  followed  by  an  almost  immediate 
disappearance  of  the  disease.  Upon  further  investigation  it 
was  discovered  that  the  impure  ice  had  been  gathered  from  a 
small,  stagnant  pond  into  which  a  small  brook  carried  large 
quantities  of  saw-dust  from  several  saw-mills.  The  water  of  the 
pond  was  loaded  with  organic  matter,  and  in  summer  the  gases 
of  decay  arising  from  it  were  very  offensive.  Chemical  exam- 
ination showed  that  the  ice  from  this  pond  contained  nearly  6 
parts  of  organic  matter  in  100,000,  while  in  pure  ice  the  organic 
matter  amounted  to  only  .3  part  in  100,000.  A  similar  inves- 
tigation into  the  character  of  the  ice  furnished  to  the  residents 
of  Newport,  R.  I.,  was  made  under  the  auspices  of  the  Sanitary 
Protection  Association  of  that  city.  The  ice,  which  was  cut 
from  ponds  in  the  immediate  neighborhood  of  the  city,  was 
found  to  contain  an  excessive  proportion  of  organic  matter. 

1  Report  Massachusetts  State  Board  of  Health,  1876,  p.  467. 


SOURCES   OF   DRINKING-WATER.  57 

Large  quantities  of  sewage  and  other  impurities  were  discharged 
into  these  ponds.1 

A  series  of  experiments  recently  made  by  Dr.  C.  P.  Pengra, 
of  Michigan,  shows2  that  the  purification  of  the  water  by  freezing 
is  in  no  sense  absolute.  In  experimenting  with  bacteria,  infusoria, 
and  other  organisms,  he  found  that  from  9  to  11  per  cent,  re- 
mained in  the  ice  and  retained  their  vitality,  so  that  when 
thawed  they  rapidly  multiplied,  and  there  was  no  apparent 
loss  of  numbers.  In  the  ordinary  process  of  freezing  the  upper 
portion  is  the  purest,  but  if  snow  or  rain  fall  upon  the  ice  and 
freeze  this  upper  layer  will  be  found  much  more  impure  than 
the  lower.  Rational  conclusions  from  these  experiments  are, 
that  ice  should  not  be  gathered  from  an  impure  source,  and  that 
an  early  harvest  of  the  ice  should  be  encouraged. 

In  a  very  recent  research,  Prudden  has  shown  that  typhoid 
bacilli  contained  in  water  are  not  entirely  destroyed  by  freezing, 
even  after  remaining  in  this  condition  for  103  days. 

Springs  and  wells  supply  the  water  for  most  persons  not 
aggregated  in  large  communities,  as  cities  and  towns.  Even  in 
the  latter  no  inconsiderable  quantity  of  the  water  used  for 
drinking  and  domestic  purposes  is  derived  from  wells.  Spring- 
water  usually  comes  from  a  source  at  a  considerable  depth  below 
the  surface;  that  is  to  say,  the  water  has  percolated  through 
thick  strata  of  soil  before  re-appearing  at  the  surface.  In  its 
passage  through  the  soil  it  has  lost  most  of  its  organic  matter, 
and  perhaps  taken  up  mineral  and  gaseous  constituents  in  larger 
quantities.  It  may  be  so  strongly  impregnated  with  the  latter 
as  to  vitiate  it  for  ordinary  use  and  to  render  it  valuable  as  a 
medicine.  Ordinarily,  however,  spring-water  is  clear,  cool,  and 
sparkling,  with  a  refreshing  taste  and  uniform  temperature,  and 
is  in  all  respects  an  agreeable  and  wholesome  beverage. 

The  character  of  well-water,  on  the  contrary,  is  often  justly 
open  to  grave  suspicion.  Being  derived  from  those  strata  of  the 

1  The  Dangers  of  Impure  Ice,  in  The  Sanitarian,  May,  1882. 

2  Private  communication  to  the  author.    The  memoir  of  Dr.  Pengra  has  been  published 
in  the  Report  of  the  Michigan  State  Board  of  Health  for  1884. 


58  TEXT-BOOK   OF   HYGIENE. 

soil  which  are  most  likely  to  be  contaminated  by  the  products 
of  animal  and  vegetable  decomposition,  the  wholesomeness  of 
the  water  is  inversely  proportional  to  the  degree  of  saturation  of 
the  soil  with  the  products  of  decay.  It  has  been  found  by 
experiment  that,  when  organic  matter  largely  diluted  witli  water 
is  allowed  to  percolate  through  soil,  it  undergoes  a  gradual 
decomposition  in  the  presence  of  certain  minute  organisms, 
nitrates  and  nitrites  being  formed  at  the  expense  of  the  ammonia 
and  other  organic  combinations.  If,  however,  the  soil  is  saturated 
with  organic  matter  in  excess,  and  in  a  state  of  concentration, 
putrefaction  takes  place,  and  the  conversion  of  the  organic 
matter  into  nitrates  and  nitrites  is  retarded.  Hence,  the  drain- 
age of  diluted  sewage  through  a  stratum  of  porous  soil,  not 
already  saturated  with  putrefying  matters,  has  no  especially  bad 
significance,  even  if  the  liquid  should  reach  a  well  used  as  a 
source  of  drinking-water.  It  is  probable  that  by  the  time  the 
liquid  portion  of  the  sewage  reached  the  well  it  would  have 
arrived  at  that  point  when  it  could  truthfully  be  termed  pure 
water.  At  the  same  time  it  must  be  remembered  that  the  puri- 
fying power  of  the  soil  cannot  be  relied  upon  if  the  supply  of 
sewage  or  other  animal  or  vegetable  impurity  is  too  abundant. 

Distillation  is  sometimes  resorted  to  for  the  purpose  of  pro- 
curing drinking-water,  especially  at  sea.  Vessels  now  generally 
carry  a  still  for  this  purpose.  The  principal  objection  to  dis- 
tilled water  is  its  insipidity,  due  to  the  absence  of  carbon  dioxide 
and  mineral  constituents,  which  give  to  good  drinking-water  its 
savor.  Distilled  water  may  be  aerated  by  passing  •  it  in  fine 
streams  through  holes  in  the  bottom  of  a  cask,  elevated  so  as  to 
allow  the  water  to  pass  through  a  considerable  stratum  of  air. 
Lead  is  sometimes  taken  up  from  the  distilling  apparatus,  and 
may  cause  lead  poisoning  in  those  using  the  water. 

Drinking-water  is  sometimes  procured  by  melting  snow  or 
ice.  It  is  not  probable  that  water  derived  from  these  sources  is 
unwholesome,  although  there  is  strong  popular  prejudice  against 
it.  Ice  and  snow  may,  however,  contain  large  amounts  of 


SOURCES   OF    DRINKING-WATER.  59 

impurities,  as  already  referred  to,1  and  be  for  this  reason  unfit 
for  use. 

The  following  qualities  are  desirable  in  water  for  drinking 
and  domestic  purposes : — 

1.  The  water  should  be  colorless,  transparent,  sufficiently 
aerated,  of  uniform  temperature  throughout  the  year,  and  with- 
out odor  or  decided  taste. 

2.  The  mineral  constituents  (magnesium  and  lime  salts) 
should  not  be  present  in  greater  proportion  than  4  or  6  parts 
per  100,000.    More  than  this  gives  to  water  that  quality  known 
as  "  hardness." 

3.  There  should  be  but  little  organic  matter  present,  and 
no  living  or  dead  animal  or  vegetable  organisms. 

4.  The  water  should  be  entirely  free  from  ammonia  and 
nitrous  acid,  and  should  contain  but  very  small  quantities  of 
nitrates,  chlorides,  and  sulphates. 

5.  It  should  contain  less  than  one  milligramme  of  lead  per 
litre.      A  larger  proportion  is  likely  to  be  followed  by  lead 
poisoning. 

IMPURITIES   IN   WATER. 

The  transparency  and  the  color  of  water  are  affected  by 
the  presence  of  suspended  or  dissolved  mineral  or  organic  mat- 
ters. If,  after  standing  for  a  time,  the  water  deposits  a  sedi- 
ment, this  is  dependent  upon  insoluble  matters.  If  the  sediment 
turns  black  when  heated  in  a  porcelain  capsule  over  an  alcohol 
or  gas  flame  it  contains  organic  matter.  If  the  sediment  or 
residue  effervesces  upon  the  addition  of  hydrochloric  acid  the 
presence  of  carbonates  is  indicated.  Water  may  be  colored  by 
metallic  salts  or  by  vegetable  matter.  It  may  also  contain  large 
quantities  of  mineral  or  organic  matter,  or  even  living  organ- 
isms, without  perceptibly  diminishing  its  transparency.  For 
example,  the  ova  of  tape-worms  may  exist  in  water  in  consider- 
able numbers,  and  yet  remain  perfectly  invisible  except  under 
the  microscope. 

1  See  pages  52  and  53. 


60  TEXT-BOOK    OF   HYGIENE. 

The  presence  of  sulphur  compounds,  or  of  various  vege- 
table and  animal  organisms  (sponges,  algae,  etc.1),  may  give  to 
water  an  unpleasant  odor  and  taste.  In  the  oil  regions  of  this 
country  most  of  the  drinking-water  is  contaminated  with  petro- 
leum, which  is  very  disagreeable  to  one  unaccustomed  to  it.  It 
is  not  probable  that  the  small  quantities  of  the  oil  imbibed  with 
the  water  have  any  deleterious  influence  upon  the  organism. 

Many  works  on  hygiene  fix  a  limit  to  the  amount  of  solid 
matter  allowable  in  drinking-water.  The  International  Con- 
gress of  Hygiene,  at  Brussels,  fixed  the  limit  at  50  parts  in 
100,000.  It  is  impossible,  however,  to  say  of  any  particular 
specimen  of  water  that  its  content  of  solid  matter,  whether  or- 
ganic or  mineral,  will  be  prejudicial  to  health  without  trial.  At 
the  same  time  it  is  prudent  to  reject  all  waters  containing  a  con- 
siderable proportion  of  solid  organic  matter,  as  determined  by 
the  degree  of  blackening  on  heating  the  sediment  or  residue 
after  evaporation. 

The  hardness  of  water  is  due  to  the  presence  of  earthy  car- 
bonates, or  sulphates,  or  both.  If  the  hardness  is  due  to  car- 
bonates it  is  dissipated  by  heat,  as  in  boiling  the  water ;  the 
carbon  dioxide  is  driven  off,  and  the  base  (calcium  or  magnesium 
oxide)  is  precipitated  upon  the  bottom  and  sides  of  the  vessel. 
This  is  termed  the  "removable  hardness."  The  hardness  due 
to  the  presence  of  earthy  sulphates  is  not  removed  upon  heating 
the  water,  and  is  termed  the  "permanent  hardness."  The  hard- 
ness depending  upon  both  the  carbonates  and  sulphates  is  called 
the  "  total  hardness." 

The  proportion  of  the  above-mentioned  earthy  salts  present 
in  a  given  specimen  of  water  is  determined  by  what  is  called  the 
soap  test.  This  test  depends  upon  the  property  which  lime  and 
magnesia  salts  possess  of  decomposing  soap  (oleate  and  stearate 
of  soda).  The  quantity  of  a  solution  of  soap  of  a  definite  com- 
position decomposed  by  a  quantity  of  hard  water  indicates  the 
amount  of  the  salts  present.  In  this  country  and  England  this 

1  See  page  52. 


IMPURITIES   IN   WATER.  61 

is  generally  expressed  in  degrees  of  Clark's  scale,  which  are 
equivalent  to  grains  of  carbonate  of  lime  per  imperial  gallon. 
Thus,  if  the  chemist  says  that  a  certain  sample  of  water  has  a 
total  hardness  of  16  degrees  he  means  that  the  earthy  salts  in  the 
sample  decompose  the  same  quantity  of  soap  that  would  he  de- 
composed by  16  grains  of  carbonate  of  lime  per  imperial  gallon. 
In  Germany  each  degree  of  the  scale  used  expresses  the  soap 
decomposed  by  1  part  of  calcium  oxide  per  100,000.  In  the 
scale  used  in  France  each  degree  corresponds  to  1  part  of  car- 
bonate of  lime  in  100,000.  So  much  of  the  hardness  of  water 
as  is  due  to  carbonates  can  be  dissipated  by  boiling,  which  drives 
off  the  free  carbon  dioxide  and  allows  the  insoluble  oxides  to 
be  deposited  as  an  incrustation  upon  the  bottom  and  sides  of 
the  vessel. 

The  standard  soap  solution  for  testing  the  hardness  of 
water  is  made  as  follows :  Dissolve  10  grammes  of  Castile  soap 
in  a  litre  of  weak  (35  per  cent.)  alcohol.  One  cubic  centimetre 
of  this  solution  precipitates  1  milligramme  of  carbonate  of  lime. 
The  test  is  made  as  follows :  To  a  definitely-measured  quantity 
of  water  (say  100  cubic  centimetres)  in  a  graduated  burette  a 
quantity  of  the  soap  solution  is  added  and  the  mixture  shaken 
up;  so  long  as  there  are  dissolved  lime  or  magnesium  salts  in 
the  water  the  soap  is  decomposed  and  no  lather  is  formed.  Soap 
solution  is  now  added  gradually  and  the  shaking  repeated  until 
there  is  evidence  of  saponification  by  the  formation  of  a  more  or 
less  permanent  lather  or  froth.  The  quantity  of  soap  solution 
used  is  noted,  and  the  test  is  repeated.  The  mean  of  the  quan- 
tity of  soap  solution  in  cubic  centimetres  used  in  the  two  ex- 
periments will  represent  approximately  the  proportion  of  salts  in 
grains  of  carbonate  of  lime  per  gallon  present,  or,  as  it  is  gen- 
erally expressed,  in  "degrees  of  hardness." 

The  scale  on  the  following  page  shows  the  quantity  of 
soap  solution  required  to  decompose  the  proportion  of  calcium 
oxide  per  100,000.x 

1  Uffelmann,  Handbuch  der  Hygiene,  p.  94. 


62  TEXT-BOOK   OF   HYGIENE. 

TABLE  IY. 

1  part  CaO  per  100,000  water  requires  5.4  c.cm.  standard  soap  solution. 

2  parts    "      "          "  "  "       9.4      "  "  "          " 

o  tl  II  II  II  tl  a  jg  2  "  a  "  " 

4  u  it  u  u  u  a  17  Q  u  a  a  a 

5  u  u  u  u  u  u  20  8  "  "  "  " 
g  u  u  u  u  u  u  24  4  "  "  "  u 

g  g        U  ((          U  U  U  U         26.2          "  "  "  " 

70"        "      "  «  «  "     28  0      "  "  "          " 

IT  5      u          u        u  "  u  u      29  8        "  "  "  " 

O  Q       U  U          tl  U  U  U        ;;  |    (;          «  U  U  it 

85"        "      "  "  "  "     33  3      '•  "  "          u 

Q   Q         U  U  It  II  U  U          35    Q  U  U  U  II 

g  5      a         u        u  u  a  u      gg  7        "  "  "  " 

]  (I  Q      u         u        u  a  u  u      38.4       "  "  "  " 

1 0  5      u         u        u  a  u  u       j(,  |        u  u  n  it, 

H   Q        U  It          U  It  U  It        ^J_g          tl  tl  tt  U 

H  5     u         u       u  u  u  it      4.3^4.       it  tt  u  it 

12  o     "        "      "          "  "  "     45  0      "  "  "          " 

If  there  are  more  than  12  parts  of  lime  in  100,000  the 
water  is  diluted  with  an  equal  proportion  of  distilled  water  and 
the  resultant  multiplied  by  two. 

Mr.  Wynter  Blyth  has  proposed  to  take  the  total  residue 
as  representing  approximately  the  total  hardness  of  the  water, 
but  Dr.  Fox  points  out  that  there  may  be  a  large  excess  of  in- 
organic solids  present  in  water  that  is  quite  soft  and  originally 
pure. 

Hard  water  is  objectionable  for  domestic  use,  as  it  is  waste- 
ful of  soap.  In  cooking  certain  vegetables,  such  as  peas  and 
beans,  the  hulls  are  not  thoroughly  softened.  In  making  infu- 
sions of  tea  and  coffee,  larger  quantities  of  these  materials  are 
needed  than  where  soft  water  is  used. 

DISEASES   DUE   TO   IMPURE    DRINKING-WATER. 

Hard  water  is  popularly  believed  to  be  the  cause  of  calcu- 
lous  diseases,  and  of  goitre  and  cretinism,  but  no  reliable  obser- 
vations are  on  record  showing  that  the  belief  is  founded  upon 


DISEASES   DUE   TO   IMPURE   DRINKING-WATER.  63 

fact.  At  the  same  time  it  is  undoubtedly  true  that  calcareous 
waters  produce  gastric  and  intestinal  derangements  in  those 
unaccustomed  to  their  use. 

Large  amounts  of  suspended  mineral  matter  are  frequently 
present  in  river- water,  and  may  give  rise  to  derangements  of  the 
digestive  organs.  If  there  is  carbonate  of  lime  present,  the 
water  can  be  easily  clarified  by  the  addition  of  a  small  quantity 
of  alum.  Sulphate  of  lime  and  a  bulky  precipitate  of  hydrate 
of  alumina  are  formed,  which  carry  the  suspended  matters  to 
the  bottom.  About  10  centigrammes  of  crystallized  alum  are 
sufficient  to  clarify  a  litre  of  water.  This  amount  of  alum  is 
too  small  to  affect  the  taste  of  the  water  perceptibly.  This 
method  is  frequently  used  to  clarify  and  render  fit  for  use  the 
water  of  the  Mississippi  River,  which  is  usually  very  muddy. 
Dr.  Parkes  quotes  the  following  striking  instance  of  the  prac- 
tical value  of  clarifying  muddy  water  by  means  of  alum.1  In 
1868  the  right  wing  of  the  Ninety-second  Regiment  of  High- 
landers, going  up  the  river  Indus,  suffered  from  diarrhoea  from 
the  use  of  the  water,  which  was  very  muddy.  The  left  wing 
of  the  same  regiment  used  water  from  the  same  source,  but  pre- 
cipitated the  suspended  matters  with  alum  and  had  no  diarrhoea. 
The  right  wing  then  adopted  the  same  plan  with  like  success. 
Although  the  opinion  is  widespread  that  water  containing  much 
mineral  matter,  either  in-  solution  or  in  suspension,  is  deleterious 
to  health,  there  is  very  little  evidence  absolutely  trustworthy 
upon  this  point. 

The  presence  of  large  quantities  of  organic  matter  in  water, 
whether  these  matters  be  of  animal  or  vegetable  origin,  must 
always  be  looked  upon  with  suspicion.  The .  observation  was 
made  by  Hippocrates  twenty-three  centuries  ago,  that  persons 
using  the  water  from  marshes,  i.e.,  water  containing  vegetable 
matter,  suffer  from  enlarged  spleens.  Many  physicians,  both  of 
ancient  and  modern  times,  seem  to  have  held  this  opinion,  but 
the  first  positive  observation  in  medical  literature  is  the  now 

1  Manual  of  Practical  Hygiene,  6th  ed.,  New  York,  vol  i,  p.  341. 


64  TEXT-BOOK   OF  HYGIENE. 

classical  one  of  the  ship  Argo,  reported  by  Boudin.1  In  1834 
the  transport  Argo,  in  company  with  two  other  vessels,  carried 
800  soldiers  from  Bona,  in  Algiers,  to  Marseilles.  The  troops 
were  all  in  good  health  when  they  left  Algiers.  All  three  of 
the  vessels  arrived  in  Marseilles  on  the  same  day.  In  two  of  them 
there  were  680  men,  not  one  of  whom  was  sick.  Out  of  the 
remaining  120  men  who  were  on  the  third  vessel,  the  Argo,  13 
died  during  the  passage,  and  98  of  the  107  survivors  suffered 
from  paludal  fevers  of  all  forms.  None  of  the  crew  of  the 
Argo  were  sick,  however.  The  two  vessels  exempt  from  sick- 
ness, and  the  crew  of  the  Argo,  had  been  supplied  with  pure 
water,  while  the  soldiers  on  the  latter  vessel  had  been  furnished 
with  water  from  a  marsh.  This  water  was  said  to  have  a  dis- 
agreeable odor  and  taste.  The  testimony  of  a  large  number  of 
East  India  physicians  is  also  quoted  by  Parkes  in  support  of 
the  view  that  malarial  fevers  are  often  caused  by  impure  drink- 
ing-water. The  observations  of  Dr.  Charles  Smart,  upon  the 
production  of  "mountain  fever"  of  the  Western  territories, 
have  already  been  referred  to.  The  author  ventures  to  state  it 
as  his  opinion,  however,  that  the  instances  in  which  malarial 
fevers  are  due  to  impure  drinking-water  are  very  rare. 

The  causation  of  typhoid  fever  and  cholera  by  impure 
drinking-water  will  be  presently  referred  to.  Recently  the 
opinion  has  been  expressed  by  some  that  yellow  fever  and  diph- 
theria are  also  spread  by  polluted  drinking-water,  but  no  strong 
evidence  has  yet  been  adduced  in  its  support. 

There  can  be  very  little  doubt  that  diarrhoea  and  dysentery 
are  frequently  caused  by  water  which  has  been  contaminated 
with  decaying  organic  matter.  The  evidence  in  favor  of  this 
amounts  practically  to  demonstration. 

It  must  not  be  forgotten  that  the  ova  of  certain  animal 
parasites,  such  as  distoma  hematobium,  filaria  sanguinis  hominis, 
and  medinensis,  anchylostoma  duodenale,  and  possibly  of  round- 

1  Quoted  in  Parkes,  op.  «'<.,  p.  48 ;  Nowak,  Lehrbuch  der  Hygiene,  p.  51 ;  and  in 
numerous  other  publications  on  Hygiene. 


DISEASES   DUE   TO   IMPURE    DRINKING-WATER.  65 

and  tape-  worms,  for  example,  are  taken  into  the  system  along 
with  the  drinking-water. 

Organic  detritus  of  various  kinds,  sewage,  decomposing 
animal  and  vegetable  matter,  refuse  from  manufacturing  estab- 
lishments, may  be  a  source  of  pollution  of  water  and  render  it 
unfit  for  drinking  or  other  domestic  purposes.  It  is,  however, 
not  certain  that  water  thus  rendered  unclean  is  prejudicial  to 
health;  in^fact,  Dr.  Emmerich,  of  Munich,  has  recently  put  his, 
skepticism  on  this  point  to  a  practical  test.  For  two  weeks  he 
drank  daily  from  half  a  litre  to  a  litre  of  very  filthy  water;  in 
fact,  nothing  less  than  sewage.  The  water  was  both  chemically 
and  physically  exceedingly  impure.  Several  of  the  experi- 
menter's patients  partook  of  the  same  water  without  any  ill 
effect.  He  even  claims  that  a  gastric  catarrh,  from  which  he 
was  suffering  when  the  experiment  was  begun,  was  improved 
during  its  course.1 

.  The  results  of  Emmerich's  experiments,  and  of  other  well- 
known  observations,  seem  almost  conclusive  that  the  products  of 
animal  and  vegetable  decomposition,  taken  into  the  body  with 
the  drinking-water,  cannot  be  looked  upon  as  certainly  harmful. 
Should,  however,  water  containing  such  impurities,  or  even 
water  apparently  pure,  contain  the  germs  of  one  of  the  specific 
diseases, — cholera,  typhoid  fever,  or,  perhaps,  yellow,  malarial, 
or  scarlet  fevers,  or  diphtheria, — it  is  probable  that  such  diseases 
would  be  communicated  to  the  consumer  of  the  water. 

Many  instances  are  on  record  where  outbreaks  of  typhoid 
fever  have  been  clearly  attributable  to  pollution  of  the  drinking- 
water  by  the  germ  of  the  disease  from  a  previous  case. 

One  of  the  most  remarkable  of  these  outbreaks  is  that  re- 
corded by  Dr.  Thorne.2  About  the  end  of  January,  1879, 
typhoid  fever  began  suddenly  in  the  adjoining  towns  of  Cater- 
ham  and  Red  Hill.  Within  six  weeks  352  cases  occurred.  All 

1  Wolffhuejrel :  Wasserversorgung,  in  Pettenkofer  u.  Ziemssen's  Handbuch  der  Hygiene, 
I  Abth.,  II  Hlfte,  p.  97. 

-  Rcp(>''t  of  the  medical  officer  totlie  Local  (iovernment  Hoard  for  1879.  Quoted  in  Fa- 
don  Hygienisuhe  Untersuchungen,  etc.,  II  Abtli.,  p.  261. 


66  TEXT-BOOK   OF   HYGIENE. 

other  sources  of  the  disease  were  excluded  except  the  drinking- 
water,  to  pollution  of  which  it  was  traced  with  almost  absolute 
certainty.  Caterham  contained  558  houses  and  Red  Hill  1700. 
Of  the  former  419  and  of  the  latter  924  drew  their  drinking- 
water  from  a  common  supply,  having  its  source  in  a  well  several 
hundred  feet  deep.  The  insane  asylum,  with  2000  inmates,  and 
the  military  barracks  in  Caterham  used  water  from  a  private 
.well.  There  was  no  typhoid  fever  among  the  last  two  commu- 
nities. During  January  one  of  the  workmen  engaged  in  some 
excavation  near  the  public  well  was  taken  ill  with  diarrhoea  and 
fever, — probably  typhoid, — but  was  still  able  to  continue  his 
work.  His  dejections  were  often  voided  where  they  were  cer- 
tain to  become  mingled  with  the  water  of  the  common  supply. 
This  man's  diarrhoea  began  on  January  5th  and  continued  until 
the  20th  of  the  month,  during  which  time  he  remained  at  work. 
On  the  latter  date  he  was  compelled  to  quit  work  and  take  to 
his  bed.  Exactly  two  weeks  from  the  beginning  of  the  man's 
sickness,  on  January  19th,  the  first  case  of  typhoid  occurred  in 
Caterham,  and  then  rapidly  increased.  The  first  case  occurred, 
therefore,  just  fourteen  days — the  incubative  period  of  typhoid 
— after  the  presumed  infection  of  the  drinking-water  by  the  de- 
jections of  the  sick  laborer,  who  had  come  from  Croydon,  where 
typhoid  fever  was  at  the  time  prevalent.  Within  two  weeks 
from  the  appearance  of  the  first  case  the  epidemic  had  reached  its 
height,  and  then  rapidly  declined,  disappearing  almost  entirely  hi 
a  month  after  the  outbreak.  It  was  shown  by  Dr.  Thome  that 
nearly  all  the  houses  in  which  the  disease  appeared  were  sup- 
plied with  water  from  the  source  above  mentioned,  while  other 
houses  in  the  immediate  vicinity  of  the  infected  ones  remained 
free  from  the  disease. 

In  1874  there  was  an  outbreak  of  typhoid  fever  in  the 
town  of  Over  Darwen,  in  which  nearly  10  per  cent,  of  the  in- 
habitants were  attacked.  Here  the  source  of  the  disease  was 
also  traced  to  an  infected  water-supply. 

Dr.  Buchanan  has  shown  that  an  outbreak  among  the  stu- 


DISEASES   DUE   TO   IMPURE    DRINKING-WATER.  67 

dents  of  the  University  of  Cambridge  was  likewise  attributable 
to  an  infected  water-supply. 

In  this  country  the  reports  of  the  Boards  of  Health  of  the 
various  States  teem  with  accounts  of  localized  outbreaks  of 
typhoid  fever,  referred  to  infected  or  polluted  drinking-water. 
In  most  instances  the  evidence  furnished  by  the  observers  is  not 
conclusive.  In  many,  however,  especially  of  those  found  in  the 
Massachusetts  and  Michigan  reports,  the  fact  of  the  communi- 
cation of  the  disease  in  this  manner  seems  unquestionable.  One 
of  these  is  as  follows :  Out  of  40  families,  all  using  water 
from  a  certain  well,  there  occurred  23  cases  of  typhoid  fever. 
Out  of  47  families,  living  in  the  same  neighborhood,  but  using 
water  from  different  sources,  only  2  had  typhoid  fever.1  Dr.  C. 
F.  Folsom  has  published  a  very  suggestive  account  of  a  house 
epidemic,2  where  9  persons  in  a  single  house,  who  all  drank  water 
from  a  well  which  was  proven  to  be  infected  from  a  privy,  were 
attacked  by  this  disease. 

In  1885  an  epidemic  of  typhoid  fever  began  in  Plymouth, 
a  mining  town  of  8000  or  9000  inhabitants,  situated  in  the 
Wyoming  coal  region  of  Pennsylvania,  and  on  the  right  bank 
of  the  Susquehanna  River.  The  epidemic  began  in  April,  and 
lasted  until  the  ensuing  September.  There  were  1104  persons 
attacked  by  the  disease,  of  which  number  114,  or  10.3  per  cent., 
died.  The  careful  inspection  made  into  the  history  of  this 
epidemic  revealed  the  fact  that  the  public  water-supply  had 
unquestionably  become  polluted  by  the  faecal  discharges  of 
typhoid-fever  patients,  and  the  entire  course  of  the  disease,  in 
this  instance,  is  in  complete  accord  with  the  view  that  the  origin 
and  spread  of  the  epidemic  were  due  to  the  pollution  of  the 
drinking-water  with  the  typhoid-fever  poison. 

In  addition,  Chantemesse  and  Vidal  have  demonstrated  the 
presence  of  the  bacillus  of  Eberth,  which  is  now  generally  rec- 
ognized as  the  cause  of  typhoid  fever,  in  drinking-water  from 

1  Transactions  Mich.  Med.  Society,  p.  401,  1883. 

»  Boston  Med.  and  Surg.  Journal,  vol.  cii,  pp.  227,  261. 


68  TEXT-BOOK   OF   HYGIENE. 

a  well  near  Paris,  to  which  a  small  outbreak  of  typhoid  had 
been  traced.  This  demonstration  has  also  been  furnished  bv 
Prof.  V.  C.  Vaughan,  in  connection  with  an  outbreak  of  the 
same  disease  in  the  State  of  Michigan. 

The  numerous  cases  of  typhoid  fever  which  have  been 
attributed  to  the  use  of  infected  milk  may  be  included  in  this 
category.  It  is  probable  that  the  milk  became  infected  either 
through  polluted  water  used  for  the  purpose  of  cleansing  the 
milk-vessels  or  in  diluting  the  milk.  Mr.  Ernest  Hart  has  re- 
corded1 50  epidemics  of  typhoid  fever,  15  of  scarlet  fever,  and 
7  of  diphtheria,  the  cause  of  which  he  has  attributed  to  infected 
milk. 

It  is  probable  that  typhoid  fever  is,  in  the  majority  of  cases, 
spread  through  the  medium  of  polluted  drinking-water,  and,  in 
many  of  the  instances  on  record,  the  relations  between  cause 
and  effect — impure  water  and  typhoid  fever — have  been  so  clearly 
made  out  as  to  no  longer  permit  any  doubt  upon  the  question. 

As  it  is  with  typhoid  fever,  so  also  with  cholera.  In  a  later 
chapter  the  origin  and  propagation  of  typhoid  fever  and  cholera 
will  be  discussed  more  fully.  At  the  present  time  only  the  rela- 
tions of  the  drinking-water  to  the  spread  of  these  diseases  can 
be  considered.  In  the  instance  to  be  presently  noted  the  con- 
nection between  the  infected  water,  on  one  hand,  and  the  out- 
break of  cholera,  on  the  other,  is  so  clearly  shown  as  to  be 
almost  equivalent  to  a  mathematical  demonstration.  The  facts 
in  the  case  were  brought  to  light  after  a  patient  inquiry  by  a 
commission,  whose  report  drawn  up  by  Mr.  John  Marshall  has 
made  the  occurrence  classical.  In  1854  the  people  of  a  well-to- 
do  and  otherwise  healthy  district  in  the  eastern  part  of  London 
suffered  severely  from  cholera.  Upon  inquiry  the  fact  was 
elicited  that  a  child  had  died  of  cholera  at  No.  40  Broad  Street, 
and  that  its  excreta  had  been  emptied  into  a  cess-pool  situated 
only  three  feet  from  the  well  of  a  public  pump  in  that  street, 
from  which  most  of  the  neighboring  people  took  their  drinking- 

1  Transactions  Seventh  Int.  Med.  Congress,  vol.  iv,  p.  391, 1881. 


DISEASES   DUE   TO   IMPURE   DRINKING-WATER.  69 

water.  It  was  further  discovered  that  the  bricks  of  the  cess- 
pool wall  were  loose  and  permitted  its  contents  to  drain  into 
the  pump-well.  (It  should  be  noted  that  the  communication 
between  the  cess-pool  and  well  was  direct ;  that  there  was  im- 
mediate drainage,  not  percolation  through  the  soil.)  In  one 
day  140  to  150  people  were  attacked,  and  it  was  found  that 
nearly  all  the  persons  who  had  the  malady  during  the  first  few 
days  of  the  outbreak  drank  the  water  from  the  pump.  When 
the  pump  was  closed  to  public  use  by  the  authorities  the  epi- 
demic subsided.  The  most  singular  case  connected  with  this 
outbreak  was  the  following :  In  West  End,  Hampstead,  several 
miles  away  from  Broad  Street,  there  occurred  a  fatal  case  of 
cholera  in  a  woman  59  years  old.  This  woman  formerly  lived 
in  Broad  Street,  but  had  not  been  there  for  many  months.  A 
cart,  however,  went  daily  from  Broad  Street  to  West  End, 
carrying,  among  other  things,  a  large  bottle  of  water  from  the 
pump  referred  to.  The  old  lady  preferred  this  water  to  all 
others,  and  secured  a  daily  supply  in  the  manner  stated.  A 
niece,  who  was  on  a  visit  to  the  old  lady,  drank  of  the  same 
water.  She  returned  to  her  home,  in  a  high  and  healthy  part 
of  Islington,  was  likewise  attacked  by  cholera  and  died.  There 
were,  at  this  time,  no  other  cases  of  cholera  at  West  End,  nor  in 
the  neighborhood  of  these  last  two  persons  attacked. 

Most  of  the  English  medical  officers  in  India  hold  strongly 
to  the  view  that  cholera  is  spread  by  polluted  drinking-water, 
and  the  evidence  in  its  favor  is  very  strong. 

Quite  recently  (in  1885)  Dr.  Robert  Koch  discovered  the 
cholera  spirillum  in  a  water-tank  in  Calcutta,  used  as  a  source 
of  domestic  supply,  and  in  this  way  furnished  another  link  in 
the  chain  of  evidence  connecting  the  spirillum,  the  drinking- 
water,  and  the  outbreak  of  the  disease. 

The  evidence  in  favor  of  the  influence  of  impure  drinking- 
water  on  the  causation  of  other  diseases  than  those  mentioned 
is  not  sufficient  to  justify  any  conclusions  at  present. 

The  source  of  a  water-supply  may  be  pure,  yet  pollution 


70  TEXT-BOOK  OF   HYGIENE. 

may  occur  before  the  water  is  used  by  the  persons  to  whom 
it  is  distributed.  Supply-pipes  may  become  defective,  and  the 
water  become  contaminated  with  sewage  or  other  deleterious 
substances.  It  is  a  current  belief  that  no  impurity  can  gain 
access  to  hydrant-pipes  between  the  reservoir,  or  source  of 
supply,  and  the  point  of  discharge  of  the  water.  Nevertheless, 
such  contamination  may  occur  very  readily.  The  author  and 
his  colleague,  Dr.  J.  W.  Chambers,  of  Baltimore,  proved  this 
conclusively  a  few  years  ago  by  establishing  an  undoubted  con- 
nection between  a  house-epidemic  of  typhoid  fever  and  a  defect 
in  the  hydrant  supplying  the  family  with  water.1  The  hydrant 
was  one  of  the  class  known  as  Clark's  patent  non-freezing 
hydrant.  The  mechanism  of  these  hydrants  is  as  follows :  At 
the  lower  end  of  the  vertical  discharge-pipe  is  a  glazed  earthen- 
ware plunger,  which  works  through  a  ring  of  rubber  packing 
into  a  vacuum  chamber.  At  the  bottom  of  the  vacuum  chamber 
is  a  valve  regulating  the  entrance  of  the  water  from  the  con- 
ducting-pipe.  When  the  water  is  shut  off  this  valve  is  kept 
closed  by  a  spiral  spring.  When  the  crank  of  the  hydrant  is 
turned  forward — that  is,  when  the  water  is  "turned  on" — the 
plunger  is  forced  to  the  bottom  of  the  vacuum  chamber,  presses 
on  the  spring,  opens  the  valve,  and  allows  the  water  to  dis- 
charge. When  the  crank  is  turned  back  the  plunger  is  raised, 
releases  the  spiral  spring,  which  forces  the  valve  into  its  bed,  and 
shuts  off  the  water.  The  partial  vacuum  produced  by  the 
raising  of  the  plunger  draws  the  water,  which  is  in  the  vertical 
discharge-pipe,  into  the  vacuum  chamber,  which  is  so  far  below 
the  surface  as  to  be  unaffected  by  frost.  In  course  of  time, 
and  with  use,  the  rubber  packing  gets  worn  and  permits  gradual 
leakage  into  the  vacuum  chamber  of  the  dirty  stagnant  water 
by  which  this  part  of  the  hydrant  is  always  surrounded.  Out- 
breaks of  typhoid  fever  having  a  similar  origin,2  in  which  the 

1  On  Preventable  Pollution  of  Hydrant- Water  and  its  Relation  to  the  Spread  of  Ty- 
phoid Fever.  Maryland  Meil.  Journal,  vol.  vii,  p.  271. 

*  Local  Causes  of  Insanitation  in  Baltimore,  by  John  Morris,  M.D.  Report  Md.  State 
Board  of  Health,  1878. 


DISEASES   DUE   TO   IMPURE   DRINKING-WATER.  71 

connection  between  cause  and  effect  was  clearly  shown,  have 
been  reported  by  other  physicians  of  the  same  city. 

Aside  from  the  practical  question  of  the  causation  of  disease 
by  polluted  water,  a  more  abstract  and  aesthetic  idea  is  involved 
in  consciously  taking  any  impurity  into  the  system.  The  in- 
stincts of  man,  as  well  as  of  most  animals,  revolt  at  it.  These 
inborn  instincts,  which  constitute  the  sanitary  conscience,  as 
Soyka  says,  demand  purity  of  food  and  water,  as  they  insist  on 
cleanliness  of  the  body,  of  clothing,  and  of  the  dwelling. 

STORAGE    AND   PURIFICATION   OF   WATER. 

Wherever  a  large  supply  of  water  is  needed,  unless  drawn 
direct  from  a  well  or  spring,  or  pumped  directly  from  its  source, 
arrangements  for  storage  are  necessary.  Cisterns  and  large 
reservoirs  are  made  use  of  for  this  purpose.  River-water,  espe- 
cially, requires  a  period  of  rest  in  a  storage  reservoir  in  order  to 
allow  deposition  of  the  large  amount  of  suspended  matter  in  it. 
Prolonged  storage  also  gives  opportunity  for  the  conversion  of 
possibly  deleterious  organic  compounds  into  simple  and  perhaps 
harmless  combinations.  Usually,  in  an  elaborate  system  of 
water- works,  a  series  of  reservoirs  is  built,  in  which  the  water  is 
stored  successively,  so  that  before  its  final  distribution  through 
the  street-mains  it  has  become  quite  clear  and  pure.  Filtration 
on  a  large  scale  is  also  used  in  connection  with  storage  reservoirs 
in  order  to  secure  greater  purity  of  the  water. 

In  the  distribution  of  water,  care  should  be  taken  that  nothing 
deleterious  is  taken  up  by  the  water  in  its  passage  through  the 
pipes.  Lead  poisoning  is  not  infrequent  from  drinking-water  that 
has  passed  through  a  long  reach  of  lead  pipe,  or  which  has  been 
standing  in  a  vessel  lined  with  lead.  Tanks  and  storage  cisterns 
should  therefore  not  be  lined  with  lead,  and  the  use  of  lead  pipe 
in  the  supply  service  should  be  avoided  as  much  as  possible. 
Fortunately,  most  natural  waters  possess  a  considerable  propor- 
tion of  carbon  dioxide,  which  forms  with  the  lead  an  almost 
insoluble  carbonate  of  lead.  This  carbonate  of  lead  is  deposited 


72  TEXT-BOOK  OF   HYGIENE. 

on  the  inside  of  the  pipes,  and  protects  both  the  pipes  against 
erosive  action  from  other  constituents  of  the  water,  and  also 
prevents  the  contamination  of  the  water  by  the  lead.  An  -excess 
of  carbon  dioxide  in  the  water  renders  this  deposit  soluble,  and 
may  cause  serious  poisoning.  Any  water  which  is  shown  by 
analysis  to  contain  over  1  milligramme  of  lead  per  100,000  is 
dangerous,  and  should  be  rejected. 

Owing  to  the  possibility  of  defilement  of  the  water  from 
improper  construction  of  hydrants,  all  outdoor  hydrants  should 
be  discouraged  as  much  as  possible,  and  should  be  replaced  by  a 
simple  tap-cock  indoors.  The  pipes  should  also  be  laid  deep 
enough  under-ground,  or  otherwise  protected  against  freezing  in 
winter. 

A  number  of  methods,  all  more  or  less  efficient,  have  been 
introduced  to  purify  water  when  it  needs  purification  before 
being  fit  for  use.  These  methods  either  comprise  filtration  or 
seek  to  purify  the  water  without  the  aid  of  this  process.  One 
of  the  methods  of  purification  without  filtration  consists  in 
exposing  the  water  to  the  air  in  small  streams.  This  was  pro- 
posed by  Lind  more  than  a  century  ago,  and  has  since  been 
frequently  revived.  The  water  is  passed  through  a  sieve,  or  a 
perforated  tin  or  wooden  plate,  so  as  to  cause  it  to  fall  for  a 
distance  through  the  air  in  finely-divided  currents.  By  this 
process  sulphuretted  hydrogen,  offensive  organic  vapors,  and 
possibly  dissolved  organic  matters  are  removed.  This  process 
has  been  used  in  Russia  on  a  large  scale. 

By  boiling  and  agitation,  carbonate  of  lime,  sulphuretted 
hydrogen,  and  organic  matter  are  removed  or  rendered  innocuous. 
Vegetable  germs  are  usually  destroyed,  although  Tyndall  has 
shown  that  some  bacterial  germs  withstand  a  temperature  higher 
than  that  of  boiling  water.  Pathogenic  germs  are,  however,  all 
destroyed  by  boiling  water  acting  upon  them  for  ten  minutes,  as 
shown  by  Dr.  G.  M.  Sternberg.1 

As  has  already  been  mentioned,2  alum  is  one  of  the  readiest 

1  Report  of  Committee  on  Disinfectants,  1888.  *  See  page  59. 


STORAGE   AND   PURIFICATION    OF   WATER.  73 

and  most  efficient  means  of  removing  suspended  matters  from 
water. 

Permanganate  of  potassium  is  sometimes  used  to  purify 
water  containing  considerable  organic  matter.  The  perman- 
ganate rapidly  oxidizes  the  organic  matter,  and  is  believed  to 
render  it  harmless.  There  is  no  certainty,  however,  that  the 
germs  of  specific  diseases  are  destroyed  by  the  action  of  this 
salt,  in  the  proportion  in  which  it  could  be  used  for  the  purposes 
of  water  purification. 

A  yellow  tint  is  given  to  the  water  by  the  permanganate, 
which  is  due  to  finely-divided  peroxide  of  manganese.  This 
does  no  harm,  but  is  unpleasant. 

Water  unfitted  for  use  by  organic  matter  is  sometimes 
rendered  usable  by  infusing  certain  vegetable  astringents  in  it. 
Thus,  it  is  said  that  in  certain  parts  of  China,  where  the  water 
contains  large  quantities  of  organic  matter,  the  inhabitants  drink 
water  only  in  the  form  of  tea.  The  tannin  of  the  tea-leaves 
precipitates  the  suspended  matters  and  renders  the  water  fit  for 
use.  Mixing  the  water  with  red  wine,  which  is  astringent,  has 
the  same  effect.1 

Filtration  is  an  efficient  means  of  removing  suspended 
matters.  Charcoal,  sand,  gravel,  and  spongy  iron  are  used  as 
filtering  material.  A  most  economical  filter  is  one  made  of  fine, 
clean  sand,  above  which  layers  of  gravel  of  a  gradually-increasing 
size  are  placed.  The  coarser  particles  of  suspended  matter  are 
arrested  before  the  sand,  which  removes  most  of  the  coloring 
and  organic  matters,  is  reached. 

Filters  easily  become  fouled  by  the  matters  arrested  in  the 
interstices  of  the  filtering  material,  and  hence  require  frequent 
renewal  or  cleansing.  A  cheap  and  efficient  filter  is  made  by 
placing  a  sheet  of  druggists'  filtering-paper  in  a  glass  funnel 
and  filtering  the  water  through  it.  A  now  and  clean  sheet  of 
paper  should  be  used  every  day. 

M.  Chamberland  has  invented  a  filter  which  is  said  to  be 

1  Champouillon,  quoted  in  Mod.  and  Surg.  Hist,  of  the  War,  part  ii  med.  vol.,  p.  613. 


74  TEXT-BOOK   OF   HYGIENE. 

absolutely  germ-proof,  but  this  power  is  not  permanent,  as  after 
a  week  micro-organisms  pass  through  the  filtering  material. 
The  same  is  true  of  all  other  niters  hitherto  invented. 


TESTS   FOR   IMPURITIES   IN   WATER. 

Accurate  and  reliable  quantitative  analyses  of  water  can 
only  be  made  by  chemists  of  experience.  Every  intelligent 
person  should,  however,  know  how  to  determine  the  presence  or 
absence  of  suspected  impurities.  The  following  methods  are 
simple,  and  easily  carried  out: — 

The  color,  transparency,  and  odor  of  water  are  determined 
by  the  unaided  senses.  As  a  standard  for  comparison  in  making 
the  color  test,  pure,  distilled  water  may  be  used.  Two  tubes  of 
clear,  white  glass,  61  centimetres  long,  are  filled  with  distilled 
water  and  with  the  specimen  to  be  tested,  and  placed  side  by  side 
upon  a  sheet  of  white  paper.  The  tops  of  the  tubes  are  covered 
with  little  squares  of  clear  glass.  The  color  is  noted  by  com- 
paring the  tints  of  the  water  in  the  two  tubes.  The  same 
procedure  may  be  used  to  determine  the  transparency  of  the 
water. 

While  the  color  and  turbidity  show  impurities,  these  are 
not  necessarily  prejudicial  to  health;  on  the  other  hand,  the 
clearest  and  most  sparkling  water  may  contain  so  much  poisonous 
matter  as  to  be  positively  dangerous.  The  odor  of  the  water  is 
best  ascertained  by  heating  a  small  quantity  in  a  narrow-necked 
flask  to  40°  to  45°  C.  (104°  to  113°  F.),  and  then  taking  a  few 
strong  whiffs  at  the  flask.  The  odor  may  or  may  not  indicate 
the  presence  of  deleterious  substances. 

The  chemical  examination  of  a  water  for  sanitary  purposes, 
short  of  a  complete  analysis,  comprises  the  determination  of  the 
presence  or  absence  of  suspected  impurities;  in  other  words,  it 
may  be  termed  a  qualitative  analysis.  In  some  cases  an  approxi- 
mate quantitative  examination  may  also  be  made  with  little 
more  trouble  and  skill. 


TESTS   FOR   IMPURITIES   IN    WATER.  75 

The  examination  may  be  divided  into  the  following  pro- 
cedures : — 

1.  The  determination  of  the  total  residue.  * 

2.  The  determination  of  the  presence  of — 

(a)  Organic  matter. 
(6)  Chlorides. 

(c)  Nitrogen  compounds. 

(d)  Mineral  poisons. 

Determination  of  Total  Solids. — Examination  of  the  public 
water-supply  of  eight  large  cities  in  the  United  States  shows 
that  the  total  solid  residue  varies  from  6  to  16  parts  in  100,000. 
The  total  solids  of  a  good  drinking-water  should  not  exceed 
25  to  30  parts  per  100,000,  although  a  larger  quantity  may  be 
present  without  being  harmful.  The  method  of  determining 
the  total  solids  is  to  evaporate  a  definite  quantity — say,  70  cubic 
centimetres  of  the  water — in  a  previously-weighed  platinum 
dish  to  dryness  over  a  water-bath.  The  dish  is  then  wiped  dry 
and  weighed  again.  The  difference  in  weight  between  the 
empty  dish  and  the  latter  with  the  dry  residue  represents  the 
proportion  of  the  latter  in  grains  per  gallon.  To  convert  this 
figure  into  parts  per  100,000  the  number  of  grains  per  gallon 
is  divided  by  .7.  For  example,  if  the  number  of  grains  of  solid 
residue  in  the  specimen  examined  is  22.4,  then 

22.4  -f-  .7  =  32  parts  per  100,000. 

Determination  of  Organic  Matter. — This  is  the  most  difficult 
test  to  apply  in  the  sanitary  examination  of  water.  While  it  is 
comparatively  easy  to  determine  the  presence  of  organic  matter, 
its  quantity  and  nature  are  exceedingly  complex  problems  to 
solve. 

The  presence  of  organic  impurity  in  water  may  be  detected 
by  the  permanganate-of-potash  test,  the  nitrate-of-silver  test, 
and  the  incineration  test.  Neither  of  these  processes  is  compe- 
tent 'to  differentiate  noxious  from  inoffensive  organic  matter. 
The  permanganate  test,  modified  by  Dr.  DeChaumont,  is  the 


76  TEXT-BOOK   OF   HYGIENE. 

one  usually  adopted.  The  process  is  as  follows:  To  250  cubic 
centimetres  of  the  water  to  be  examined  add  5  cubic  centimetres 
of  dilute  sulphuric  acid  (10  per  cent.)  in  a  clear,  white  glass 
flask.  Then  add  permanganate  of  potassium  solution  (395 
milligrammes  to  1  litre  of  distilled  water)  until  the  water  has 
taken  a  pink  tinge.  Heat  the  water  to  140°  F.  (60°  C.),  adding 
permanganate  solution  if  the  color  disappears.  When  the  tem- 
perature above  mentioned  is  reached  remove  the  flask  from  the 
burner,  and  add  permanganate  drop  by  drop  until  a  faint  .pink 
color  is  obtained,  which  remains  permanent  for  ten  minutes. 
Read  off  the  number  of  cubic  centimetres  of  the  permanganate 
solution  used  as  required  for  total  oxidizable  matter.  As  the 
solution  of  permanganate  yields  in  presence  of  an  acid  0.1  of  a 
milligramme  of  oxygen  for  each  cubic  centimetre,  it  is  evident  that 
the  number  of  cubic  centimetres  of  solution  decomposed  has 
furnished  an  equal  number  of  tenths  of  a  milligramme  of  oxygen 
which  has  entered  into  other  combinations. 

But,  inasmuch  as  all  the  oxidizable  matter  in  the  water 
may  not  be  organic,  the  inorganic  oxidizable  matter  (nitrous 
acid)  must  be  separated.  This  is  done  by  first  boiling  the  water 
with  sulphuric  acid,  as  above  (250  cubic  centimetres  -f-  5  cubic 
centimetres),  for  twenty  minutes,  to  remove  the  nitrous  acid. 
Then  allow  the  acidulated  water  to  cool  down  to  60  degrees 
and  add  the  permanganate  until  a  pink  color  is  obtained  for  ten 
minutes.  The  amount  of  permanganate  solution  used  gives  the 
number  of  milligrammes  of  oxygen  required  for  oxidizable 
organic  matter. 

Determination  of  Chlorides. — Chlorine,  or  its  compounds, 
when  present  in  drinking-water,  represent  generally  sewage 
pollution.  It  is  true  that  chlorine  may  be  in  excess  in  water, 
and  the  latter,  nevertheless,  be  entirely  free  from  sewage  or 
urine,  but  this  occurs  only  where  there  is  a  natural  deposit  of 
chlorine  compounds  in  the  soil  from  which  the  supply  is  drawn. 
If  communication  with  the  sea  or  salt-deposits  is  excluded,  the 
chlorine  may  be  assumed  to  be  due  to  the  inflow  of  sewage. 


TESTS  FOR   IMPURITIES   IN   WATER.  77 

Especially  is  this  the  case  if  the  test  for  organic  matter  has  given 
positive  results.  The  proportion  of  chlorine  may  be  estimated 
thus:  Place  70  cubic  centimetres  of  the  water  into  an  evapo- 
rating dish,  and  add  a  small  fragment  of  neutral  chromate  of 
potash.  Then,  by  means  of  a  pipette  .graduated  to  tenths  of  a 
cubic  centimetre,  standard  solution  of  nitrate  of  silver1  should 
be  allowed  to  drop  into  the  water  until  the  red  color  produced 
remains  permanent.  The  number  of  cubic  centimetres  of  the 
silver  solution  required  to  produce  the  permanent  red  tint  is 
equivalent  to  the  number  of  grains  of  chlorine  per  gallon,  which, 
if  divided  by  .7,  gives  the  parts  per  100,000. 

Another  method  of  determining  the  presence  of  chlorine  or 
chlorides  is  as  follows:  Acidulate  about  16  cubic  centimetres  of 
the  water  to  be  tested  with  pure  nitric  acid,  and  add  a  few  drops 
of  a  solution  of  nitrate  of  silver  (1.5  grammes  to  32  cubic  cen- 
timetres of  distilled  water).  A  white  precipitate,  gradually 
changing  to  gray,  is  produced  if  chlorides  are  present.  The 
degree  of  cloudiness  produced  will  indicate  approximately  the 
amount  of  chlorides:  "1.5  parts  of  chlorine  per  100,000  give 
a  haze;  5.7  parts  per  100,000  give  a  marked  turbidity;  14  parts 
per  100,000,  considerable  precipitate."  If  the  chlorine  is  found 
by  this  test  to  exceed  1.5  parts  per  100,000,  the  source  of  the 
contamination  should  be  searched  for.  If  drainage  from  a  cess- 
pool is  suspected,  a  quantity  of  salt  water  may  be  thrown  into 
it,  and  the  water  again  tested  after  an  interval  of  four  hours  to 
see  whether  the  chlorine  has  increased. 

Determination  of  Nitrites  and  Nitrates. — The  presence  of 
these  nitrogen  compounds  in  drinking-water  should  excite  sus- 
picion of  sewage  contamination.  They  are  the  resultants  of 
oxidation  of  nitrogenous  organic  matter,  and,  although  water 
containing  them  is  not  necessarily  dangerous,  their  presence 
should  render  a  thorough  examination  of  the  source  of  supply 
imperative. 

1  Standard  Solution  of  Nitrate  of  Silver.— Dissolve  4.79  grammes  of  crystallized  nitrate 
of  silver  in  1  litre  of  distilled  water.  One  cubic  centimetre  of  this  solution  precipitates  1  milli- 
gramme of  chlorine. 


78  TEXT-BOOK   OF   HYGIENE. 

The  readiest  method  of  detecting  nitrates  and  nitrites  in 
water  is  by  the  pyrogallol  test.  This  may  be  performed  as  fol- 
lows :  Put  2  cubic  centimetres  of  pure  sulphuric  acid  in  a  small 
test-tube  and  add  1  cubic  centimetre  of  the  water  to  be  tested. 
To  this  mixture  is  added  1  drop  of  a  solution  of  pyrogallol 
(65  centigrammes  to  30  cubic  centimetres)  in  distilled  water, 
acidulated  with  2  drops  of  sulphuric  acid.  The  water  becomes 
colored  a  dark  amethyst  or  wine  brown  if  the  salts  are  present. 
The  depth  of  color  indicates  approximately  the  amount  of  the 
impurity. 

The  following  test  for  nitric  acid  or  nitrates  may  also  be  used : 
A  small  quantity  of  the  water  is  evaporated  to  dryness,  and  a 
few  drops  of  a  solution  of  carbolic  acid  in  4  parts  of  con- 
centrated sulphuric  acid  and  2  parts  of  distilled  water  added 
to  the  residue.  If  nitric  acid  is  present,  a  brownish-red  color 
results,  which  turns  green  and  then  yellow  upon  the  addition  of 
ammonia. 

Nitrous  acid  or  nitrites  will  give  a  reaction  with  iodide  of 
potassium  and  starch ;  350  to  600  cubic  centimetres  of  water 
in  a  flask  are  acidulated  with  a  few  drops  of  dilute  sulphuric 
acid,  and  a  little  solution  of  iodide  of  potassium  added.  About 
2  grammes  of  freshly-prepared  starch  are  added  and  the  mixture 
shaken.  If  nitrous  acid  is  present,  the  iodide  is  decomposed, 
setting  free  the  iodine,  which  combines  with  the  starch,  causing 
a  blue  color.  The  test  is  a  very  delicate  one. 

Ammonia. — The  presence  of  this  is  determined  by  Nessler's 
reagent,1  as  follows:  100  cubic  centimetres  of  the  water  to  be 
examined  is  treated  with  0.5  cubic  centimetre  of  caustic  soda 
solution  and  1  cubic  centimetre  of  carbonate  of  soda  solution 
to  precipitate  the  earthy  salts.  After  the  precipitate  has  sub- 
sided, 1  cubic  centimetre  of  Nessler's  reagent  is  added.  If 
ammonia  is  present  the  water  takes  a  yellowish  tint. 

1  Nessler's  Reagent. — Dissolve  by  heating  and  stirring  35  grammes  of  potassium  iodide 
and  13  grammes  of  mercuric  chloride  in  800  cubic  centimetres  of  distilled  water.  Add  gradually  a 
cold  aqueous  saturated  solution  of  mercuric  chloride  until  the  red  color  produced  just  begins 
to  be  permanent ;  160  grammes  of  solid  caustic  potash  are  then  added  to  the  mixture  which  is  to 
be  diluted  with  distilled  water  until  it  exactly  measures  one  litre. 


TESTS   FOR    IMPURITIES   IN    WATER. 


79 


Determination  of  Mineral  Poisons. — Of  these  the  most 
important  are  lead,  copper,  zinc,  and  arsenic.  The  presence  of 
any  of  these  in  even  the  smallest  quantity  is  dangerous,  and,  if 
constant,  the  water  so  contaminated  should  not  be  used  for 
drinking  purposes. 

In  order  to  detect  lead  250  cubic  centimetres  of  the  water 
is  first  treated  with  hydrochloric  acid,  and  then  sulphuretted 
hydrogen  (in  aqueous  solution)  is  added.  If  a  brownish  or 
black  precipitate  results,  either  lead  or  copper  may  be  present. 

On  filtering  the  water,  dissolving  the  residue  in  hot,  diluted 
nitric  acid,  and  adding  a  solution  of  potassium  bichromate,  a 
yellow  precipitate,  soluble  in  caustic  potash,  is  thrown  down  if 
lead  is  present.  If  the  precipitate  produced  by  sulphuretted 
hydrogen  is  dissolved,  as  above,  and  ammonia  added,  a  blue 
color  is  produced  in  the  presence  of  copper.  To  detect  zinc  the 
sulphuretted  hydrogen  precipitate  is  treated  with  caustic  soda, 
again  filtered,  and  sulphuretted  hydrogen  added  to  the  filtering 
liquid.  A  white  precipitate  indicates  the  presence  of  zinc. 

Arsenic  is  detected  by  Marsh's  test.  Mr.  A.  J.  Cooper  has 
prepared  the  following  table  showing  the  accuracy  of  certain 
tests  employed  for  the  determination  of  poisonous  metals  in 

drinking-water : — 

TABLE  Y. 


Metal. 

Reagent. 

Depth  of  Liquid,  3% 
Inches. 

Depth  of  Liquid,  14J^ 
Inches  (cylinder  inclosed 
in  opaque  tube). 

1  part  of  metal  detected  in 

1  part  of  metal  detected  in 

Copper 

K4Cy6Fe 

4,000,000  of  water. 

11,750,000  of  water. 

Copper 

NH4HO 

1,000.000 

1,950,000 

' 

Copper 

H.8 

4,150,000 

15,660,000 

' 

Zinc      . 

NH4HS 

2,500,000 

Arsenic 

H2S 

3,600,000 

7,520,000 

' 

Lead     . 

K2CrO4 

4,000,000 

5,875,000 

' 

Lead    . 

H2S 

100,000,000 

196,000,000 

In  making  the  tests  a  tall  glass  is  used,  and  the  formation 
of  the  precipitate  observed  by  looking  down  perpendicularly 
through  the  column  of  liquid  of  3f  inches  (95  millimetres)  and 
14J  inches  (368  millimetres)  respectively. 


TEXT-BOOK   OF   HYGIENE. 


SIGNIFICATION    OF   THE  VARIOUS   IMPURITIES   INDICATED    BY   THE 
FOREGOING   TESTS. 

The  following  summary  gives,  briefly,  the  inferences  that 
may  be  drawn  from  the  result  of  the  foregoing  tests1 : — 

"  If  chlorine  be  present  in  considerable  quantity  it  either 
comes  from  strata  containing  chloride  of  sodium  or  calcium, 
from  impregnation  of  sea- water,  or  from  admixture  of  liquid 
excreta  of  men  and  animals.  In  the  first  case  the  water  is 
often  alkaline  from  sodium  carbonate  ;  there  is  an  absence,  or 
nearly  so,  of  oxidized  organic  matters,  as  indicated  by  nitric  and 
nitrous  acids  and  ammonia,  and  of  organic  matter;  there  is 
often  much  sulphuric  acid.  If  it  be  from  calcium  chloride  there 
is  a  large  precipitate  with  ammonium  oxalate  after  boiling.  If 
the  chlorine  be  from  impregnation  with  sea-water,  it  is  often  in 
very  large  quantity ;  there  is  much  magnesia,  and  little  evidence 
of  oxidized  products  from  organic  matters.  If  from  sewage  the 
chlorine  is  marked,  and  there  is  coincident  evidence  of  nitric  and 
nitrous  acids  and  ammonia,  and  if  the  contamination  be  recent 
of  oxidizable  organic  matters. 

"Ammonia  is  almost  always  present  in  very  small  quan- 
tity, but  if  it  be  in  large  enough  amount  to  be  detected  without 
distillation  it  is  suspicious.  If  nitrates,  etc.,  be  also  present,  it 
is  likely  to  be  from  animal  substances,  excreta,  etc.  Nitrates 
and  nitrites  indicate  previously-existing  organic  matters,  prob- 
ably animal,  but  nitrates  may  also  arise  from  vegetable  matter, 
although  this  is  probably  less  usual.  If  nitrites  largely  exist  it 
is  generally  supposed  that  the  contamination  is  recent ;  the  co- 
incidence of  easily-oxidized  organic  matters,  of  ammonia,  and 
of  chlorine  in  some  quantity,  would  be  in  favor  of  an  animal 
origin.  If  a  water  gives  the  test  of  nitric  acid,  but  not  of 
nitrous  acid,  and  very  little  ammonia,  either  potassium,  sodium, 
or  calcium  nitrate  is  present,  derived  from  soil  impregnated 
with  animal  substances  at  some  anterior  date.  If  nitrites  are 

1  Parkes'  Hygiene,  vol.  i,  p.  79. 


SIGNIFICATION    OF   VARIOUS   IMPURITIES.  81 

present  at  first,  and  after  a  few  days  disappear,  this  arises  from 
continued  oxidation  into  nitrates ;  if  nitrates  disappear  it  seems 
probable  this  is  caused  by  the  action  of  bacteria  or  other,  low 
forms  of  life.  Sometimes  in  such  a  case  nitrites  may  be  formed 
from  the  nitrates.  Lime  in  large  quantity  indicates  calcium  car- 
bonate if  boiling  removes  the  lime,  sulphate  or  chloride  or  ni- 
trate if  boiling  has  little  effect.  Testing  for  calcium  carbonate 
is  important  in  connection  with  purification  with  alum.  Sul- 
phuric acid  in  large  quantity,  with  little  lime,  indicate  sulphate 
of  sodium,  and  usually  much  chloride  and  carbonate  of  sodium 
are  also  present,  and  on  evaporation  the  water  is  alkaline. 
Large  evidence  of  nitric  acid,  with  little  evidence  of  organic 
matter,  indicates  old  contamination ;  if  the  organic  matter  be 
large,  and  especially  if  there  be  nitrous  acid  as  well  as  nitric 
present,  the  impregnation  is  recent." 

THE   BIOLOGICAL  OR   BACTERIOLOGICAL   EXAMINATION  OF   DRINKING- 
WATER. 

Since  the  development  of  the  methods  of  cultivation  of 
micro-organisms  by  Koch  and  his  pupils,  and  their  employment 
for  the  study  of  water  pollution  by  Meade  Bolton,  Wolff  hiigel 
and  Riedel,  Percy  Frankland,  Prudden,  and  others,  and  the  un- 
satisfactory results  of  chemical  analysis,  some  sanitarians  have 
expressed  the  conviction  that  the  biological  method  is  the  only 
exact  one  for  determining  water  pollution  from  a  sanitary  point 
of  view.  While  this  may  be  conceded,  it  is  also  true  that  very 
few  health  officers  are  competent  to  give  an  expert  opinion  upon 
the  nature  of  the  organisms  which  may  be  found  in  the  water 
examined.  It  requires  but  little  technical  skill  to  make  cultiva- 
tions of  bacteria  from  samples  of  water,  but  only  an  expert 
bacteriologist  may  safely  pronounce  upon  the  nature  of  the 
organisms  constituting  the  various  colonies  which  develop  upon 
the  nutritive  gelatin.  Just  as  the  mere  presence  of  organic 
matter  as  determined  by  the  chemist  is  not  indicative  of  a  dan- 
gerous quality  in  the  water  unless  the  kind  of  organic  matter 


82 


TEXT-BOOK    OF    HYGIENE. 


and  its  derivation  be  also  specified,  so  likewise  the  presence  of 
bacteria  alone  is  of  small  significance ;  the  danger  consists  not 
in  bacteria,  but  in  certain  kinds  of  bacteria.  The  differential 
diagnosis  is  possible  only  to  the  trained  bacteriologist. 

While,  as  stated,  a  positive  decision  as  to  the  sanitary  value 
of  a  water  may  often  be  impossible,  there  are  certain  chemical 
and  microscopical  features  which  stamp  a  water  as  good  or  bad. 
Dr.  DeChaumont  gives  an  approximate  valuation  which  may 
often  serve  as  a  useful  guide.1 

He  classifies  water  under  the  four  heads  of  Pure  and 
Wholesome  Water,  Usable  Water,  Suspicious  Water,  and  Im- 
pure Water.  The  characters  of  these  waters  are  arranged  in  a 
series  of  tables,  the  essential  details  of  which  are  given  in 
Table  VI. 

TABLE  VI. 


CHEMICAL 

PUKE 

WATER. 

USABLE 
WATER. 

SUSPICIOUS 
WATER. 

IMPURE 
WATER. 

CONSTITUENTS. 

I. 

Parts  in  100,000. 

II. 

Parts  in  100,000. 

m. 

Parts  in  100,000. 

IV. 

Parts  in  100,000. 

Chlorine  in  solution  . 

Under  1.4000 

Under  4.2857 

4-7 

Above  7.142S 

Solids           "  total     . 

"      7.1428 

"     42.8571 

43-71 

71.4285 

"                "  volatile 

"      1.4000 

"      4.2857 

4-7 

7.1428 

Ammonia,  free  or  sa- 

line     

"      0.0020 

"      0.0050 

0.0050-0.0100 

0.0100 

Ammonia,  albuminoid 

"       0.0050 

"      0.0100 

0.0100-0.0125 

0.0125 

Nitric  acid  in  nitrates 

"      0.0323 

"      0.5000 

0.5-1.0 

1  0000 

"         "  nitrites 

Nil. 

Nil. 

0.0500 

0.0500 

Nitrogen  in  nitrates   . 

"      0.0140 

"      0.1129 

0.1243-0.2373 

0  2415 

Total  nitrogen  .     .     . 

"      0.0230 

"      0.1252 

0.1255-0.2465 

0.2(501 

Oxygen   absorbed  by 

permanganate    and 

acid  within  half  an 

hour  at  140°  F.  .     . 

"      0.0250 

"      0.1000 

0.1000-0.1500 

"      0.1500 

Total  hardness  .     .     . 

"      8.5 

"    17.3 

Above  17.0 

"    28.5 

Permanent  hardness  . 

"      3.0 

"      5.7 

"      5.7 

"      8.7 

Phosphoric     acid     in 

phosphates     .     .     . 

Traces. 

Traces. 

Heavy  traces. 

Heavy  traces. 

Sulphuric  acid  in  sul- 

phates     

« 

Under  3.000 

Above  3.000 

Above  4.2857 

Heavy  metals    .     .     . 

Nil. 

Traces. 

Traces. 

(  Any  except 
|       iron. 

Hydrogen  sulphide    . 

" 

Nil. 

Nil. 

Present. 

Alkaline  sulphides 

1  Parkes'  Hygiene,  vol.  i,  pp.  103-106. 


EXAMINATION    OF   DRINKING-WATER. 


83 


PHYSICAL  CHARACTERS. 

No.  I.  Colorless,  or  bluish  tint ;  trans- 
parent, sparkling,  and  well  aerated  ;  no 
sediment  visible  to  naked  eye ;  no  smell ; 
taste  palatable. 

No.  II.  Colorless,  or  slightly  greenish 
tint ;  transparent,  sparkling,  and  well 
aerated  ;  no  suspended  matter,  or  else 
easily  separated  by  coarse  filtration  or 
subsidence  ;  no  smell ;  taste  palatable. 

No.  III.  Yellow,  or  strong,  green 
color ;  turbid  ;  suspended  matter  con- 
siderable ;  no  smell,  but  any  marked 
taste. 

No.  IV.  Color,  yellow  or  brown  ;  tur- 
bid, and  not  easily  purified  by  coarse 
filtration  ;  large  amount  of  suspended 
matter  ;  any  marked  smell  or  taste. 


MICROSCOPICAL  CHARACTERS. 
No.    I.     Mineral  matter ;    vegetable 
forms  with  endochrome;  large  animal 
forms  ;  no  organic  debris. 

No.  II.    Same  as  No.  I. 


No.  III.  Vegetable  and  animal  forms 
more  or  less  pale  and  colorless  ;  organic 
debris  ;  fibres  of  clothing,  or  other  evi- 
dences of  house-refuse. 

No.  IV.  Bacteria  of  any  kind ;  fungi ; 
numerous  vegetable  and  animal  forms 
of  low  types  ;  epithelia,  or  other  animal 
structures  ;  evidences  of  sewage  ;  ova 
of  parasites,  etc. 


[The  following  works  are  recommended  to  those  desiring 
fuller  information  upon  the  subjects  embraced  in  the  foregoing 
chapter : — 

Water  Supply,  by  Wm.  Ripley  Nichols,  N.  Y.,  1884. — A  Guide  to 
the  Microscopic  Examination  of  Drinking- Water,  by  J.  D.  MacDonald, 
R.N.F.R.S. — Sanitary  Examinations  of  Water,  Air,  and  Food,  by  Fox. — 
Report  of  the  Committee  on  Water  Pollution,  Public  Health,  vol.  xiv. 
Zeitschr.  f.  Hygiene,  vol.  i,  by  Bolton. — Prudden  in  N.  Y.  Medical 
Record,  1887. — Arb.  aus  d.  Reichsgesundheitsamte,  I,  Wolffhiigel  and 
Riedel. — Kenwood  :  The  Hygienic  Laboratory,  Part  I.] 


QUESTIONS   TO   CHAPTER  II. 

WATER. 

For  what  purposes  do  people  need  water?  Why  should  the  supply 
be  pure?  What  is  the  quantity  needed  by  each  person  daily,  and  what 
quantity  should  be  supplied  per  head  in  towns  and  cities  for  all  purposes  ? 
How  may  waste  of  water  be  prevented  ?  What  is  the  objection  to  the 
use  of  water-meters  ? 

What  is  the  original  source  of  all  fresh  water?  How  is  rain-water 
usually  collected  and  stored?  What  are  the  objections  to  underground 
cisterns?  What  is  the  only  material  of  which  underground  cisterns 
should  be  made  ? 

What  impurities  may  rain-water  contain  ?  Why  is  it  so  valuable  for 
domestic  purposes?  What  is  the  great  objection  to  the  use  of  rain- 
water ? 

From  what  source  do  most  cities  and  towns  derive  their  water- 
supply  ?  What  precautions  must  be  observed  regarding  such  a  source  ? 
What  are  some  of  the  minor  objections  to  the  use  of  river-water? 
What  peculiar  diseases  ma3T  be  due  to  such  water?  What  is  the  most 
serious  objection  to  the  use  of  river-water  for  domestic  purposes? 

How  does  a  running  stream  purify  itself?  Can  this  self-purification 
be  relied  upon?  Can  it  be  stated  definitely  when  a  stream  once  polluted 
becomes  fit  for  use  again  ?  Is  it  safe  to  use  water  from  a  stream  known 
to  have  been  contaminated  by  sewage  ? 

What  is  usually  the  quality  of  water  from  fresh-water  lakes  and 
ponds  ?  What  large  city  uses  lake-water  entirely  ?  What  precautions 
must  be  observed  regarding  such  .a  source  of  supply?  To  what  is  the 
offensive  taste  and  odor  of  water  from  small  lakes  or  storage-reservoirs 
often  due  ? 

Does  water  purify  itself  absolutely  in  freezing  ?  What  matters  may 
be  found  in  ice  ?  Are  all  pathogenic  micro-organisms  destroyed  by 
freezing  ?  What  part  of  ice  is  the  purest  ? 

What  class  of  persons  usually  derive  their  drinking-water  from 
springs  and  wells  ?  What  is  the  relative  purity  of  spring-  and  of  well- 
water  ?  Why  ?  AYhat  changes  take  place  in  diluted  organic  matter  in 
percolating  through  the  soil?  To  what  are  these  changes  due?  What 
mav  retard  or  check  these  changes  ?  Is  water  containing  nitrites  and 

(84) 


QUESTIONS   TO   CHAPTER   II.  85 

nitrates  necessarily  dangerous  ?     Of  what  are  nitrites  and  nitrates  an 
indication  ? 

What  is  the  principal  objection  to  the  use  of  distilled  water  as  a 
beverage,  and  how  may  this  objection  be  overcome?  What  metallic 
poison  may  be  taken  up  from  the  distilling  apparatus  ? 

Name  some  of  the  qualities  that  are  desirable  in  water  for  drinking 
or  domestic  purposes.  When  is  a  water  said  to  be  hard  ? 

What  may  affect  the  color  and  transparency  of  water  ?  Of  what 
may  the  sediment  in  water  be  composed  ?  What  impurities  may  there 
be  in  perfectly  colorless  and  transparent  water  ?  How  may  the  presence 
of  sulphur  compounds  be  detected  ?  What  is  the  usual  amount  of  solid 
matter  permissible  in  water.  What  class  of  solid  constituents  especially 
should  cause  a  water  to  be  rejected  ? 

To  what  is  the  hardness  of  water  due?  What  is  the  distinction 
between  "  removable  "  or  u  temporary  "  and  "  permanent  "  hardness, 
and  what  is  meant  by  "  total "  hardness  ?  How  is  the  degree  of  hard- 
ness determined,  and  upon  what  does  the  test  depend  ?  Describe  the 
test.  What  is  meant  by  Clark's  scale  ?  Why  is  hard  water  objection- 
able for  domestic  use  ? 

What  diseases  and  derangements  of  health  may  be  due  to  hard 
water?  Is  the  evidence  absolute  regarding  all  of  these?  What  troubles 
may  large  amounts  of  suspended  mineral  matter  cause?  How  may 
such  water  be  clarified  ?  What  mineral  in  the  water  is  essential  to  the 
process  ? 

What  may  be  the  effect  of  large  quantities  of  organic  matter  in  the 
water?  What  infectious  diseases  may  be  due  to  impure  drinking-water? 
What  other  organisms  harmful  to  health,  other  than  bacteria,  may  be 
found  in  drinking-water?  Name  some  notable  places  where  epidemics 
have  been  undoubtedly  caused  by  impure  drinking-water.  How  may  a 
milk-supply  be  infected  by  impure  water?  How  might  a  water  be  pol- 
luted in  distribution,  even  though  the  source  be  pure? 

What  is  the  advantage  of  a  prolonged  storage  of  river-water? 
What  waters  should  not  be  stored  in  lead-lined  cisterns  or  conveyed  in 
leaden  pipes  ?  What  is  the  greatest  amount  of  lead  permissible  in  water  ? 

In  what  ways  may  water  be  purified  on  a  large  scale  ?  How  may  the 
hardness  of  water  be  partially  removed  ? 

What  methods  may  be  used  in  the  household  for  the  purification  of 
water  ?  How  may  the  water  be  softened  ?  How  may  disease  germs  and 
other  organisms  in  water  be  destroyed  ?  How  may  organic  matter  be 
removed  ?  What  are  some  good  filtering  materials  ?  What  are  some  of 


86  QUESTIONS   TO   CHAPTER   II. 

the  essential  requisites  of  a  good  house-filter  ?  What  is  necessary  that 
every  house-filter  may  be  safe  for  use  ?  Are  any  filters  absolutely  germ- 
proof? 

How  are  the  color,  transparency,  and  odor  of  water  determined, 
and  what  is  the  standard  of  comparison  ?  Is  a  turbid  or  colored  water 
necessarily  harmful,  and  may  a  perfectly -clear  water  be  dangerous  to  use  ? 

How  are  the  total  solids  of  a  water  determined  quantitatively  ? 
Describe  the  permanganate-of-potash  test  for  the  determination  of  the 
organic  matter  in  water.  What  does  an  excess  of  chlorine  or  chlorides 
in  water  generally  indicate,  and  why  ?  How  may  these  be  determined 
quantitatively  ?  If  sewage  contamination  of  a  water  be  suspected,  how 
may  the  suspicion  be  confirmed  ?  Why  should  the  presence  of  nitrites  or 
nitrates  in  water  excite  the  suspicion  of  sewage  contamination  ?  Give  a 
test  for  each.  By  what  reagent  is  the  presence  of  ammonia  determined  ? 
How  may  the  presence  of  lead,  copper,  zinc,  or  arsenic  be  detected? 

How  may  we  know  whether  an  excess  of  chlorides  is  due  to  sewage 
contamination  or  not?  What  is  the  probable  source  of  ammonia  if  in 
excess  and  in  company  with  nitrates,  etc.  ?  Which  is  supposed  to  in- 
dicate the  most  recent  contamination,  nitrites  or  nitrates  ?  May  nitrates 
arise  from  vegetable  matters  rather  than  animal  ?  What  does  the  pres- 
ence of  nitrates  without  nitrites  or  ammonia  indicate  ?  What  lime-salt 
is  most  readily  removed  by  boiling  ? 

What  relation  has  the  organic  matter  to  the  nitric  acid  ?  Why  is  it 
not  easy  to  make  a  biological  or  bacteriological  examination  of  water? 

Into  what  four  classes  may  water  be  divided  ?  Name  some  of  the 
characteristics  of  these  different  classes. 


CHAPTER  III. 
FOOD. 

IN  order  to  preserve  health  and  vigor  it  is  necessary  for 
animal  beings  to  consume  at  intervals  a  sufficient  quantity  of 
substances  known  as  foods.  Alimentary  substances,  .or  foods, 
may,  therefore,  be  briefly  defined  as  materials  which,  taken  into 
the  body  and  assimilated,  sustain  the  processes  of  life,  promote 
growth,  or  prevent  destruction  of  the  organized  constituents  of 
the  body. 

QUANTITY   AND   CHARACTER   OF  FOOD   NECESSARY. 

It  has  long  been  known,  as  the  result  of  the  empirical 
observation  of  feeding  large  bodies  of  people,  that  the  various 
proximate  principles  composing  the  tissues  must  be  combined  in 
certain  definite  proportions  in  the  food  in  order  to  preserve  the 
normal  degree  of  health  and  vigor  of  the  body.  Within  a 
comparatively  recent  period  physiologists  have  made  experi- 
ments upon  animals  and  human  beings  which  have  led  to  the 
same  conclusions,  and  have  enabled  these  proportions  to.  be 
fixed  with  more  or  less  exactness. 

Considering  man  as  an  omnivorous  animal,  it  may  be  laid 
down  as  an  invariable  rule  that  the  following  four  alimentary 
principles  are  necessary  to  his  existence.1  Neither  of  these 
principles  can  be  dispensed  with  for  a  prolonged  period  without 
illness  or  death  resulting. 

1.  Water. — This  must  be   supplied  in  sufficient  quantity 
to  permit  the  interchange  of  tissue  to  be  carried  on  in  the  body. 

2.  /Salts. — Inorganic    compounds   of    various   kinds    are 

1  Physiologic,  Landois,  2te  Aufl.,  p.  448. 

.(87) 


88  TEXT-BOOK    OF    HYGIENE. 

necessary  to  the  preservation  and  proper  construction  of  the 
tissues.  They  are  all  found  in  sufficient  quantities  in  the 
various  alimentary  substances  consumed  by  man  and  the  lower 
animals.  A  deficiency  of  inorganic  constituents  in  the  food  is 
followed  by  disease. 

3.  Proteids. — Organic  nitrogenous  material,  either  animal 
or  vegetable,  is  a  necessary  constituent  of  the  food  of  man. 
Continued  existence  is  impossible  without  a  sufficient  supply  of 
nitrogenous  substances. 

4.  Fats  or  Carbohydrates. — The  organic  non-nitrogenous 
or  carbonaceous  principles  of  food  are  also  necessary  to   the 
continuance  of  health.     They  are  supplied  either  by  fats  or  by 
carbohydrates  (sugar,  starch,  etc.),  which  may,  within  certain 
limits,  be  used  as  substitutes  for  each  other.     Voit  has  shown 
that  17  parts  by  weight,  of  starch,  is  equivalent  as  carbonaceous 
or  oxidizable  food  to  10  parts  of  fat. 

The  physiology  of  nutrition  has  been  very  carefully  studied 
by  a  large  number  of  experimental  physiologists,  who  have 
arrived  at  conclusions  differing  widely  from  those  generally 
accepted  twenty-five  years  ago.  The  division  of  foods  into 
plastic  and  respiratory  foods,  or,  in  a  general  way,  into  proteids 
or  muscle-builders,  and  fats  and  carbohydrates,  or  oxidizing 
foods,  is  now  no  longer  recognized  in  science.  It  has  been 
established  that  proteid  tissues  are  not  alone  the  result  of  proteid 
food,  and  that  the  accumulation  of  fat  in  the  body  is  not  altogether 
due  to  the  excessive  consumption  of  fats  and  carbohydrates.  It 
has  been  further  shown,  contrary  to  the  general  belief,  that  the 
nitrogenous  or  proteid  tissues  are  not  used  up  during  hard  labor 
any  faster  than  when  at  perfect  rest,  but  that,  on  the  contrary, 
increased  muscular  exertion  is  attended  by  increased  consump- 
tion of  stored-up  fat. 

These  facts  have  led  to  a  modification  of  the  standard 
dietaries  formerly  employed.  At  present  the  standards  of  the 
quantity  of  food  principles  required  to  maintain  equality  between 
bodily  income  and  expenditure  are  those  calculated  by  Professor 


QUANTITY   AND    CHARACTER    OF   FOOD    NECESSARY. 


89 


Voit,  after  many  experiments  upon  human  beings  and  the  lower 
animals.     These  standards  are  as  follow : — 


TABLE  VII. 

ADULT    MALE   OP    AVERAGE    WEIGHT. 


At  Rest. 

Moderate  Labor. 

Severe  Labor. 

Proteids  .... 
Fats  

110  grammes 
50       " 

118  grammes 
50       " 

145  grammes 

100       " 

Carbohydrates  .  . 

450       " 

500       " 

500       " 

As  the  average  weight  of  women  is  less  than  that  of  men, 
a  reduction  of  from  15  to  20  per  cent,  in  the  various  food  prin- 
ciples may  be  made  for  the  female  ration. 

The  relative  proportion  of  nitrogenous  to  non-nitrogenous 
principles  in  this  ration  is  about  1  to  5.  Tn  the  older  diet 
standards,  e.g.^  Moleschott's,  the  proportion  of  nitrogenous  to 
non-nitrogenous  principles  is  much  larger,  being,  for  a  man  at 
moderate  labor,  proteids,  130  grammes;  fats,  84  grammes;  and 
carbohydrates,  404  grammes,  or  about  1  to  3.75. 

While  from  ignorance,  or  motives  of  economy,  many  men 
sustain  life  and  preserve  health  at  hard  labor  on  rations  varying 
considerably  from  the  standard  above  given,  it  is  probable  that, 
all  things  being  considered,  the  most  perfect  physiological  ration 
would  also  be  the  most  economical.  Thus,  Professor  Vaughan 
proposes  a  daily  ration  consisting  of  bread,  cod-fish,  lard,  potatoes, 
bacon,  beans,  milk,  sugar,  and  tea  in  such  proportions  as  to  fur- 
nish 123  grammes  proteids,  70  grammes  fats,  and  550  grammes 
carbo-hydrates.  The  total  cost  or  money  value  of  this  ration  at 
present  prices  is  about  thirteen  cents.  In  actual  food  value  it 
is  not  inferior  to  the  daily  fare  of  the  habitue  of  Delmonico's. 

The  above  standard  diet-tables  give  the  relative  proportions 
of  food  principles  in  terms  of  their  proximate  chemical  composi- 
tion. In  practice  it  is  very  necessary  to  choose  such  food  ma- 
terials as  will  represent  approximately  the  proximate  principles 


90 


TEXT-BOOK   OF   HYGIENE. 


required.  The  following  tables  give  the  approximate  value  in 
proteids,  fats,  carbohydrates,  and  salts  of  a  number  of  articles 
used  as  food: — 

TABLE  VIII. 


ANIMAL   FOODS. 


ARTICLES. 

» 

Water 
(per  cent.). 

Proteids  * 
(per  cent.). 

Fats 
(per  cent.). 

Non-nitrogenous 
Matters 
(per  cent.). 

Ash 
(percent.). 

Proportion  of 
Nitrogenous  to 
Non-nitrogenous 
Matters. 

Moderately  fat  beef      .... 

72.25 

21.39 

5.19 

1.17 

1:      0.4 

Ox-heart  (fat  animal)  .... 
Fat  veal    

70.08 
72.31 

21.51 

18.88 

7.47 
7.41 

0.16 
007 

0.78 
1  33 

1:      0.6 

1:      0.7 

Moderately  fat  mutton     .    .    . 
Lean  pork    

75.99 

72  57 

18.11 
19  91 

5.77 
6  81 

1  ^^ 

I.  oo 

1  10 

1:      0.6 
1-      06 

Salt  ham       

62.58 

22.32 

8  68 

6.42 

1:      0.7 

74  16 

23.34 

1  13 

0  19 

1  18 

1:      01 

Venison    

75  76 

19.77 

1  92 

1  42 

1.13 

1:      02 

Horse-flesh  

7427 

21.71 

2  55 

0  46 

1  01 

1:      0.2 

Liver-sausage  .    .               ... 

48  70 

15  93 

26  33 

6  38 

2  66 

1:      3.3 

Beef-extract    

21  70 

60  79 

17  51 

Chicken  (lean)  

76.22 

19.72 

1.42 

127 

1.37 

1:      0.2 

Pigeon  

75.10 

22.14 

1  00 

076 

1.00 

1:      0.1 

Wild  duck  

70  82 

22  65 

3  11 

2  33 

1  09 

1-      03 

Haddock  .    .           ... 

80.92 

17  09 

035 

1  64 

1:      00 

80  71 

10.11 

7  11 

207 

1:      00 

75  49 

22.23 

047 

1.71 

1-      00 

Mackerel  

68.27 

23.42 

6.76 

1.85 

1:      0.5 

Conger-eel   

79.91 

13.57 

5.02 

039 

1.11 

1:      0.7 

Salmon      

76  38 

13  10 

4  57 

4  67 

1  28 

1-      10 

Carp  

76.97 

20.61 

1.09 

1.33 

1:      01 

Pike           .           

77.45 

20.11 

0  69 

092 

083 

1:      0.1 

Sole    

86.14 

11.94 

0  25 

045 

1  22 

1:      0.1 

89.69 

4.95 

0  37 

2  62 

2  37 

1:      0.7 

Caviar   
Beef-liver     

45.05 

72.02 

31.90 
19.59 

14.14 
5  60 

1  10 

8.91 
1  69 

1:      0.8 
1:      0.5 

Calf's  brains               

74.14 

(8  albumen) 

13  14 

1    0 

70.00 

27.00 

035 

11  65 

1    0 

Fat  of  pork  (salt)      

9  15 

9  72 

75  75 

5  38 

1-    13  6 

Hen's  esrff     .                       ... 

73.67 

12.55 

12.11 

055 

1.12 

1:      1.7 

White  of  egg  • 

85.75 

12.67 

0.25 

0.59 

1:      0.1 

Yelk  of  egg     

50.82 

16.24 

31.75 

0.13 

1.09 

1:      3.4 

Cow's  milk      

87.41 

3.31 

3.66 

4.92 

0.70 

1:      3.4 

Human  milk           

87.09 

2.48 

3  90 

6.04 

0.49 

1:      5.2 

Cream       

66.41 

3.70 

25.72 

3.54 

0.63 

1:    13.1 

Rich  cheese     

35.75 

27.16 

30.43 

2.53 

4.13 

1:      2.1 

Lean  cheese    

48.02 

32.65 

8.41 

6.80 

4.12 

1:      0.7 

Butter  

14.14 

0.86 

83.11 

0.70 

1.19 

1:  169.9 

Whey        

93.31 

0.82 

0.24 

4.98 

0.65 

1:      6.6 

Kuinys  

87.88 

2.83 

0.94 

7.08 

1.07 

1:      3.1 

Condensed  milk.               .    .    . 

30.34 

16.07 

12.10 

38  882 

2  61 

1:      37 

Containing  16  per  cent,  nitrogen. 


a  Containing  22.26  per  cent,  cane-sugar. 


QUANTITY    AND    CHARACTER   OF   FOOD    NECESSARY. 


91 


TABLE  IX. 

VEGETABLE    FOODS. 


ARTICLES. 

Water 
(per  cent.). 

Proteids 
(percent.). 

Fats 
(per  cent.). 

Sugar 
(per  cent.). 

Other  Non-nitro- 
genous Mat- 
ters (per  cent.). 

Woody  Fibre 
(per  cent.). 

Ash 
(per  cent.). 

Proportion  of 
Nitrogenous  to 
N  o  n  -  n  itroge- 
nous  Matters. 

Wheat                

13  56 

1242 

1  70 

1  44 

66  45 

2  66 

1  77 

1      57 

Spelt.              

1209 

11.02 

2.77 

6644 

5  47 

2  21 

1      65 

Rye 

15  26 

11.43 

1.71 

096 

66  86 

2  01 

1  77 

1      62 

Barley  

13.78 

11.16 

2.12 

65  51 

480 

2  63 

1      62 

Oats  .              

12  92 

11.73 

604 

222 

53  21 

1083 

3  05 

1      56 

1388 

10.05 

476 

4.59 

62  19 

2  84 

1  69 

1      75 

Hulled  rice  

1323 

7  81 

069 

76  40 

0  78 

1  09 

1     99 

Millet  

11.26 

11.29 

3.56 

1.18 

66  15 

4.25 

2  31 

1     65 

Buckwheat  

11  36 

10  58 

2  79 

55  84 

16  52 

2  91 

1     57 

Beans          

14.84 

23.66 

1.63 

49  25 

7.47 

3.15 

1     22 

1431 

22.63 

1.72 

53  25 

5.45 

2  65 

1     25 

12  51 

24.81 

1.85 

5478 

3.58 

247 

1     28 

Wheat-flour   

1486 

8  91 

1  11 

2.32 

71  86 

0.33 

0  61 

1     85 

Rye-flour  

14.42 

10.97 

1.95 

3.88 

65.86 

1.62 

1.48 

1     6.7 

Barley-flour  

15  06 

11  75 

1  71 

3.10 

67  80 

0  11 

047 

1     63 

Buckwheat-flour  .... 

14.27 
1046 

928 
15  50 

1.89 
6.11 

1.06 
2.25 

71.40 
61.42 

0.89 
2.24 

1.21 
2.02 

1     8.2 
1     4.8 

Cornmea^ 

1400 

11  10 

8  10 

65  10 

1  70 

1     67 

Starch  

14.84 

1.46 

83.31 

0.39 

1    57.1 

Macaroni     .    .       .... 

13.07 

9.02 

0.28 

76.79 

0.84 

1      8.6 

Fine  wheat-bread.   .    .    . 
Fresh  rye-bread   .... 
English  biscuit  

38.51 
4402 
7.45 

6.82 
6.02 
7.18 

0.77 
0.48 
9.28 

2.37 
2.54 
17.02 

49.97 
45.33 

58.08 

0.38 
0.30 
0.16 

1.18 
1.31 
0.83 

1      7.9 

1     8.1 
1    12.7 

75.77 

1.79 

0.16 

20.56 

0.75 

0.57 

1    11.6 

Beet  (red)          

87.88 

1.07 

0.11 

6.55 

2.43 

1.02 

0.94 

1      8.6 

Sugar-beet             .... 

83.91 

2.08 

0.11 

9.31 

2.41 

1.14 

1.04 

1      5.7 

9051 

1.40 

4.68 

2.14 

1.27 

1      5.8 

Carrot  (large)   

8705 

1.04 

0.21 

6.74 

2.66" 

1.40 

0.90 

1      9.4 

88.32 

1.04 

0.21 

1.60 

7.17 

0.95 

0.71 

1     8.8 

Turnip  

91.24 

0.96 

0.16 

4.08 

1.90 

0.91 

0.75 

1      6.5 

Radish     

86.92 

2.92 

0.11 

1.53 

6.90 

1.55 

1.07 

1      4.5 

Horseradish.  

76.72 

2.73 

0.35 

15.89 

2.78 

1.53 

1     6.0 

85.01 

2.95 

0.22 

0.40 

8.45 

1.76 

1.21 

1     3.1 

Onion  

70  18 

2.68 

0.10 

5.78 

19.91 

0.81 

0.54 

1     9.6 

87.62 

2.83 

0.29 

0.44 

6.09 

1.49 

1.24 

1     2.5 

Garlic          

64.66 

6.76 

0.06 

26.31 

0.77 

1.44 

1     3.9 

95.60 

1.02 

0.09 

0.95 

1.33 

0.62 

0.39 

1     2.4 

95.21 

1.06 

0.61 

0.27 

1.15 

1.07 

0.63 

1     2.4 

Pumpkin  

90.01 

0.71 

0.05 

1.36 

5.87 

1.36 

0.64 

1    10.2 

92.87 

1.25 

0.33 

2.53 

1.55 

0.84 

0.63 

1     3.6 

93.32 

1.98 

0.28 

0.40 

2.34 

1.14 

0.54 

1      1.6 

80.49 

5.75 

0.50 

10.86 

1.60 

0.80 

1      2.0 

Snap  beans  

86.10 

4.67 

0.30 

6.60 

1.69 

0.64 

1      1.5 

Cauliflower    

90.39 

2.53 

0.38 

1.27 

3.74 

0.87 

0.82 

1      2.2 

Winter  cabbage  

80.03 

3.99 

0.90 

1.21 

10.42 

1.88 

1.57 

1      3.3 

Savoy  cabbage      .... 

87.09 

3.31 

0.71 

1.29 

4.73 

1.23 

1.64 

1      2.2 

Red  cabbage          .... 

85.63 

4.83 

0.46 

6.22 

1.57 

1.29 

1      1.5 

Spinach  

90.26 

3.15 

0.54 

0.08 

3.26 

0.77 

1.94 

1      1.3 

Lettuce   .    •           .... 

94.33 

1.41 

0.31 

2.19 

0.73 

1.03 

1      1.9 

TEXT-BOOK   OF   HYGIENE. 
TABLE  IX.  (continued). 

VEGETABLE   FOODS. 


ARTICLES. 

"Water 
(per  cent.). 

Proteids 
(per  cent.). 

Fats 
(per  cent.). 

Sugar 
(per  cent.). 

Other  Non-nitro- 
genous Mat- 
ters (per  cent.). 

Woody  Fibre 
(per  cent.). 

Ash 
(per  cent.). 

Proportion  of 
Nitrogenous  to 
N  o  n  -  n  itroge- 
nous  Matters. 

Mushrooms  (fresh)  .   .    . 
"          (dried)  .   .    . 
Truffle    

91.11 
17.54 

7280 

2.57 
23.84 
891 

0.13 
1.21 
062 

1.05 
9.59 

3.71 
34.56 
754 

0.67 
•  6.21 

7  92 

0.76 
7.05 
2  21 

1:    1.9 
1  :    1.9 
1-10 

Apples  1  

83.58 

0.39 

7.73 

5  17 

1.98 

0.31 

1  :  35  2 

83  03 

0.36 

826 

3.54 

430 

0.31 

1  :33  3 

8486 

040 

3.56 

4.68 

4  34 

0.66 

1  :  24  3 

8003 

0.65 

448 

7.17 

6.06 

0.69 

1  •  19  3 

81.22 

049 

469 

6.35 

5.27 

0.82 

1  :249 

Cherries  

80.26 

0.62 

10.24 

1  17 

6.07 

0.73 

1  :19  9 

78  17 

059 

14  36 

1  96 

360 

053 

1-290 

87.66 

1.07 

0.45 

6.28 

0.48 

2.32 

0.81 

1:78 

86  21 

0.53 

3.95 

1.54 

5.90 

049 

1  :13  0 

Blackberries  

8641 

051 

4.44 

1  76 

5  21 

048 

1  :  145 

84.71 

0.36 

9.19 

2  31 

0.91 

0.66 

1  :37  1 

Whortleberries  

78.36 

0.78 

5.02 

0.87 

1229 

1.02 

1:97 

85.74 

0.47 

7.03 

1.40 

352 

0.42 

1  :21  0 

Currants  .       

84.77 

0.51 

6.38 

090 

457 

0.72* 

1  :  18  5 

Dried  apples  

32.42 

1.06 

41  61 

14.68 

5  59 

1.96 

1  :55  6 

pears   

29.41 

2.07 

0.35 

29.13 

29.67 

686 

1.67 

1  :29.1 

prunes  
cherries  

29.83 

49.88 

255 

2.07 

0.53 
030 

42.65 
31.22 

18.85 
14.29 

1.43 
0.612 

1.39 
1.63 

1  :25.5 
1  :22  2 

32.02 

2.42 

0.59 

54.56 

7.48 

1.72 

1.21 

1  :260 

fics  . 

32.21 

5.06 

45.28 

2.96 

1:89 

Sweet  almonds  .'.... 

5.39 

24.18 

5368 

7.23 

6.56 

2.96 

1:42 

Walnut           

4.68 

16  37 

62.86 

7.89 

6.17 

2  03 

1:72 

Hazel-nut   ;  . 
Chestnuts  (fresh)    .    .*  . 
Peanut.   t    

3.77 
51.48 
G.50 

15.62 
548 

28.20 

66.47 
1.37 
46.40 

•    • 

9.03 

38.34 
15.70 

3.28 
1.61 

1.83 
1.72 
3.20 

1  :    8.0 
1  :    7.5 
1  :    2.3 

In  addition  to  maintaining  a  proper  proportion  between  the 
various  alimentary  principles,  it  is  necessary  to  vary  the  articles 
of  food  themselves,  otherwise  they  are  liable  to  prove  nauseating. 
The  necessity  of  variety  in  the  food,  in  order  to  preserve  the 
appetite,  is  familiar  to  every  one. 

By  keeping  the  proportions  of  the  above  table  in  view  it 
will  be  seen  at  once  that  if  a  man  wished  to  live  on  beef  alone 
he  would  be  obliged  to  eat  about  2  kilogrammes  per  day  in 
order  to  get  a  sufficient  amount  of  non-nitrogenous  food.  Of 


1  Those  green  fruits  all  contain  in  addition  from  .2  to  2.1  per  cent,  of  free  acid. 
'  Without  stones. 


QUANTITY   AND   CHARACTER   OF   FOOD   NECESSARY.  93 

potatoes,  in  order  to  get  enough  nitrogenous  food,  he  would  have 
to  eat  daily  8  kilogrammes.  No  human  stomach  could  prove 
equal  to  the  task  of  digesting  this  excess  of  material.  On  the 
other  hand,  it  is  to  be  noted  how  perfect  the  combination  of  the 
/various  principles  is  in  human  milk.  In  cows'  milk,  which  is 
nearest  in  composition  to  human  milk,  the  non-nitrogenous 
principles  are  deficient.  Hence,  the  important  practical  point 
that  when  ordering  milk  diet  for  a  patient  a  small  portion  of 
carbonaceous  food  (bread,  rice,  or  sugar)  must  be  added  if  the 
standard  of  health  shall  be  reached  or  maintained. 

Climate  has  probably  very  little  influence  upon  the  amount 
of  food  required  by  the  individual.  The  actual  quantity  of  food 
consumed  varies  little  between  various  races  or  in  different  parts 
of  the  earth.  It  is  true,  however,  that  a  larger  proportion  of  fat 
is  required  in  cold  climates.  That  fatty  articles  of  food  readily 
undergo  oxidation  and  furnish  a  large  amount  of  animal  heat  is 
proven  both  by  observation  and  experiment. 

The  albuminoid  proximate  principles  of  the  food,  proteids, 
are  represented  by  the  nitrogenous  constituents  of  organic 
tissues.  These  are  the  vitellin  and  albumin  of  eggs,  albumin, 
fibrin,  globulin,  myosin,  syntonin,  and  other  nitrogenized  prin- 
ciples of  flesh  and  blood  ;  the  casein  of  milk,  the  gluten,  fibrin, 
and  legumin  of  cereal  and  leguminous  seeds  and  plants,  gelatin, 
and  chondrin. 

Fat  constitutes  an  integral  component  of  animal  tissue,  and 
is  found  in  abundance  as  a  constituent  of  nerve-tissue,  marrow, 
and  subcutaneous  connective  tissue.  In  food  it  is  represented 
especially  in  the  fatty  tissue  of  meat,  the  yelk  of  eggs,  butter, 
etc. 

The  carbohydrates  are  represented  especially  by  various 
products  of  the  vegetable  world,  as  sugar,  starch,  dextrin,  etc. 

Water  and  the  various  other  inorganic  proximate  princi- 
ples, chief  among  which  are  compounds  of  calcium,  sodium,  and 
potassium,  are  usually  found  in  sufficient  proportion  in  the  other 
alimentary  substances. 


94  TEXT-BOOK   OF   HYGIENE. 

The  food  should  be  taken  in  appropriate  quantities  and 
properly  prepared.  A  larger  quantity  than  necessary  may  over- 
tax the  digestive  organs  and  thus  yield  less  than  the  required 
amount  of  nutritive  material  to  the  body. 

Physical  exertion  increases  the  consumption  of  fatty  prin- 
ciples. Hence,  as  in  the  cases  of  the  athlete  or  prize-fighter  in 
training,  larger  quantities  of  these  principles  are  required  to  keep 
the  nutrition  of  the  body  at  the  standard  of  health.  During 
mental  work,  however,  less  carbohydrate  material  is  consumed 
than  during  physical  labor. 

The  greater  consumption  of  carbohydrates  during  muscular 
exercise  is  shown  by  the  following  table,  which  gives  the  amounts 
of  carbon  dioxide  and  nitrogen  excreted  by  a  man  at  rest  and 

during  labor : — 

TABLE  X. 


CO,  Excreted. 

Nitrogen  Excreted. 

At  rest  

912  grammes 

36.3  grammes. 

At  work      

1284         " 

36.3         " 

In  youth  the  processes  of  combustion  (production  of  carbon 
dioxide)  go  on  with  greater  rapidity  than  after  adult  life  is 
reached.  For  this  reason  young  persons  rarely  get  fat,  the  fat- 
producing  food  being  burnt  up  in  the  body  by  the  greater  meta- 
bolic activity  of  the  young  cell.  Hence,  fats  and  carbohydrates 
should  form  a  larger  relative  proportion  in  the  diet  of  the  young 
than  in  that  of  grown  persons. 

Low  external  temperature  causes  a  greater  and  more  rapid 
consumption  of  fat  than  high  external  temperature.  During 
febrile  conditions,  however,  the  destruction  of  stored-up  fat  in  the 
body — the  wasting  away — is  one  of  the  most  notable  phenomena ; 
hence  the  importance  of  supplying  fat  and  fat-producing  food 
in  chronic  febrile  diseases. 

"Der  Mensch  ist  was  er  isat"  said  Ludwig  Feuerbach.1 

1  Gottheit,  Freiheit  und  Unsterblichkeit  von  Standpunkt  der  Anthropologie,  p.  5. 


CLASSIFICATION   OF  FOODS.  95 

The  pungency  of  the  epigram  is  somewhat  lost  in  the  transla- 
tion, which  is,  literally,  "Man  is  what  he  eats"  The  intimate 
relations  of  mental,  moral,  and  physical  conditions  of  health  to 
the  quality  and  quantity  of  food  deserve  the  earnest  attention 
of  the  educated  physician  and  sanitarian. 

CLASSIFICATION   OF   FOODS. 

Foods  and  victuals  are  generally  divided  into  foods  proper 
and  so-called  >accessory  aliment.  The  classification  is  not  exact, 
however,  as  the  latter,  which  are  commonly  regarded  as  articles 
of  luxury,  may  under  certain  circumstances  become  necessities, 
and  hence  should  not  be  considered  as  forming  a  separate  class. 

Foods  are  either  of  animal  or  vegetable  origin.  Those  de- 
rived from  animal  sources  are  milk,  the  flesh  of  animals,  birds, 
reptiles,  and  fish,  and  the  eggs  of  the  three  last  named. 

The  foods  derived  from  the  vegetable  kingdom  comprise 
the  seeds  of  various  plants  (cereals,  legumes),  roots,  herbs,  ripe 
fruits,  the  fleshy  envelopes  of  various  seeds  (which  may  prop- 
erly be  classed  with  the  fruits),  and  various  fungi. 

There  are  also  in  common  use  a  number  of  beverages,  e.gr., 
water,  alcoholic  liquors,  alkaloidal  infusions  (tea,  coffee,  cocoa), 
etc. 

In  addition,  a  number  of  substances  or  compounds  are  in 
common  use  as  condiments.  Their  function  is  either  to  render 
victuals  more  palatable,  or  to  promote  digestion  and  assimilation. 
Vinegar,  mustard,  and  common  salt  are  familiar  examples. 

FOODS   OF   ANIMAL   ORIGIN. 

Milk. — Human  milk  is,  so  far  as  known,  the  one  perfect 
food  for  man  found  in  nature.  It  contains,  in  proper  proportion, 
representatives  of  all  the  different  classes  of  proximate  principles 
necessary  to  nutrition.  One  hundred  parts  contain  about  2.5 
parts  of  proteids  (casein  and  albumin)  ;  3.9  parts  of  fat  (butter) ; 
6.0  parts  of  sugar,  and  .5  of  salts.  The  reaction  of  human 
milk  is  slightly  alkaline ;  that  of  fresh  cows'  milk  is  neutral. 


96  TEXT-BOOK   OF   HYGIENE. 

In  human  milk  there  are  12.9  parts  of  solid  matter  to  87.1 
of  water,  while  in  cows'  milk  the  proportions  are:  Proteids,  4.0 
per  cent. ;  fats,  3.4  per  cent ;  sugar,  3.8  per  cent. ;  salts,  0.6  per 
cent.,  or  11.8  total  solids  and  88.2  water.1 

Of  the  solids  in  milk,  cows'  milk  contains  more  proteids, 
while  human  milk  is  richer  in  fats  and  sugar.  Hence,  in  using 
cows'  milk  as  a  substitute  for  human  milk  the  proteids  are  di- 
luted by  the  addition  of  water,  and  the  non-nitrogenous  com- 
ponents increased  by  adding  sugar  and,  under  some  circum- 
stances, fat  (cream). 

Goats'  and  asses'  milk  are  sometimes  used  as  substitutes 
for  human  milk,  but  they  do  not  approach  much  nearer  in  com- 
position to  the  latter  than  does  cows'  milk. 

On  standing,  the  fatty  constituent  of  milk,  the  cream,  sepa- 
rates, and  on  account  of  its  less  specific  gravity  rises  to  the 
surface,  where  it  forms  a  layer  of  varying  thickness. 

After  standing  a  longer  interval  the  milk  undergoes  certain 
physical  and  chemical  changes.  Lactic  acid  is  formed  at  the 
expense  of  part  of  the  sugar  of  milk  (a  sort  of  fermentation 
taking  place),  and,  acting  upon  the  casein,  produces  coagulation. 
This  is  the  so-called  "bonny-clabber."  When  the  fermentation 
continues,  especially  under  a  slightly  elevated  temperature,  the 
solid  portion  becomes  condensed  (curd),  and  a  sweetish-acid, 
amber-colored  liquid,  the  whey,  separates.  The  curd,  after 
further  fermentation,  under  appropriate  treatment,  becomes 
converted  into  cheese. 

Whey  is  sometimes  used  alone  or  mixed  with  wine  as  an 
article  of  diet  for  the  sick. 

Butter  is  made  from  the  cream  by  prolonged  agitation  in  a 
churn.  The  fat-globules  adhere  to  each  other  and  form  a  soft, 
unctuous  mass,  of  a  yellowish  color,  solid  at  ordinary  tem- 
peratures. After  the  butter  is  all  removed  in  this  way  the 
balance  of  the  cream  remains  in  the  churn  as  buttermilk.  This 
is  an  article  of  considerable  nutritive  value,  although  its  excess 

1  Average  of  a  number  of  analyses. 


FOODS   OF   ANIMAL   ORIGIN.  97 

of  acid   renders   it   unsuitable  as  an  article  of  diet  in  man) 
cases. 

The  specific  gravity  of  fresh  milk  should  not  be  below 
1030.  It  should,  however,  be  borne  in  mind  that  the  richest 
milk  is  not  always  that  which  has  the  highest  specific  gravity. 
In  fact,  a  sample  of  rich  milk,  containing  a  large  proportion  of 
cream,  may  show,  when  tested  with  the  lactometer,  a  lower 
specific  gravity  than  a  specimen  of  much  poorer  milk.  Hence, 
the  lactometer,  although  a  useful  instrument  in  guarding  against 
excessive  dilution  of  the  milk  with  water,  is  not  a  very  trust- 
worthy guide  in  determining  the  quality  of  the  milk. 

Objections  are  often  urged  against  the  use  of  so-called 
"  skim-milk,"  i.e.,  milk  from  which  the  cream  has  been  removed. 
In  some  cities  in  this  country  the  police,  or  representatives  of 
the  sanitary  authorities,  seize  and  confiscate  all  skim-milk  found 
in  possession  of  dealers.  There  appears  to  be  no  rational  basis' 
for  the  opinion  held  by  many  that  skim-milk  is  not  a  proper 
and  useful  article  of  food.  Before  the  lactic-acid  fermentation 
has  taken  place  it  differs  from  fresh  milk  merely  in  the  fatty 
and  other  matters  removed  in  the  cream.  It  contains  nearly  all 
of  the  proteids,  sugar,  and  salts  of  whole  milk,  and  may  be  used 
as  an  article  of  food  with  great  advantage  and  entire  safety.  In 
certain  diseased  states  it  is  of  exceptional  value  as  an  article  of 
diet.  The  sole  objection  of  any  weight  to  skim-milk  is  that  it 
may  be  at  times  sold  fraudulently  as  fresh  milk.  This  is,  how- 
ever, a  question  of  little  sanitary  interest,  but  one  principally  of 
commercial  ethics. 

Milk  is  frequently  adulterated  by  the  addition  of  water. 
More  deleterious  substances  are  rarely  found.  An  excess  of 
water  gives  the  milk  a  bluish  tinge  and  reduces  its  specific 
gravity.  The  addition  of  water  may  become  especially  dangerous 
by  introducing  the  virus  of  some  of  the  acute  infectious  diseases. 
Thus,  the  localized  epidemics  of  typhoid  and  scarlet  fevers  have, 
in  quite  a  number  of  instances,  been  traced  to  mixing  the  milk 
with  water  containing  the  poison  of  these  diseases.  It  should, 


98  TEXT-BOOK   OF    HYGIENE. 

however,  be  stated  that  milk  which  contains  the  virus  of  typhoid 
fever  has  not  necessarily  been  adulterated  by  the  addition  of 
water.  The  poison  may  have  been  introduced  with  the  water 
used  in  washing  the  can,  and  adhered  to  the  sides  of  the  latter. 
In  filling  the  can  with  milk  a  good  culture  medium  is  supplied 
in  which  the  typhoid  bacillus  flourishes. 

It  has  long  been  a  mooted  question  whether  acute  or  chronic 
infectious  diseases  of  the  milk-giving  animal  may  be  communi- 
cated to  persons  using  the  milk  of  such  animals.  While  there 
is  little  positive  knowledge  upon  the  subject,  it  would  seem 
prudent  to  avoid  the  use  of  milk  from  diseased  animals,  if  pos- 
sible, or  to  destroy  any  organic  virus  the  milk  may  contain  by 
previously  boiling  the  milk.  After  thorough  boiling  little  fear 
need  be  entertained  of  communicating  either  acute  or  chronic 
infectious  diseases  through  this  medium.  Demme  and  Uffel- 
mann  have  reported  cases  which  seem  to  demonstrate  the  pos- 
sibility of  tuberculous  infection  through  the  medium  of  the  milk. 
Professor  Bang,  of  Copenhagen,  has  recently  made  a  series  of 
experiments  and  observations  which  has  led  him  to  the  con- 
clusion that  the  milk  of  tuberculous  cows  and  tuberculous 
women,  in  which  there  are  no  lesions  in  the  mammary  gland, 
only  exceptionally  contains  the  contagium.  Professor  Bang  at 
the  same  time,  however,  points  out  that  the  milk  from  tubercu- 
lous udders  is  extremely  dangerous,  and  that  the  tubercle  bacilli 
are  to  be  found  not  only  in  the  milk  itself,  but  in  the  cream, 
buttermilk,  and  butter  made  from  it;  and  that  such  milk  is 
sometimes  infective  by  ingestion,  even  after  exposure  to  65°  C. 
of  heat,  and  by  injection  into  the  peritoneal  cavity  after  exposure 
to  80°  C. 

The  infectiousness  of  the  milk  of  cows  suffering  from 
splenic  fever  (milzbrand,  anthrax)  has  been  proven  by  Bollinger 
and  Feser.  Anthrax  bacilli  have  been  found  in  such  milk  by 
Chambrelent  and  Moussons. 

The  agency  of  milk  in  the  spread  of  scarlet  fever  is  well 
recognized,  but  the  manner  in  which  the  contagium  gained 


FOODS   OF   ANIMAL   ORIGIN.  99 

access  to  the  milk  was  not  well  understood.  Recently,  however, 
an  incident  happened  in  England  which  seems  to  prove  a  close 
connection  between  this  widespread  and  fatal  disease  and  a  dis- 
order in  the  milk  cattle.  The  evidence  in  support  of  this  view  is 
as  follows :  Mr.  W.  H.  Power,  of  the  English  Local  Government 
Board,  was  detailed  to  investigate  certain  outbreaks  of  scarlet 
fever  which  seemed  to  have  especial  relation  to  the  milk-supply 
from  a  particular  dairy-farm.  Upon  inspection  this  dairy  was 
found  to  be  in  excellent  sanitary  condition  as  regards  cleanliness, 
water-supply,  sewerage,  etc.,  and  for  a  time  considerable  difficulty 
was  experienced  in  locating  the  cause  of  the  outbreaks.  Im- 
probable as  it  may  at  first  sight  appear,  it  seems  to  have  been 
incontestably  established  that  the  epidemics  of  scarlatina  were 
due  to  the  use  of  milk  obtained  from  cows  attacked  by  a  peculiar 
disease  manifested  by  a  vesicular  eruption  followed  by  ulceration 
of  the  udder.  The  chain  of  circumstances  connecting  the  dis- 
ease in  the  cows  with  the  outbreaks  of  scarlet  fever  in  certain 
districts  in  London,  supplied  with  milk  from  the  diseased  cows, 
was  so  strongly  forged  by  the  able  investigator,  into  whose  hands 
the  work  had  been  committed  by  the  authorities,  that  hardly  a 
doubt  can  exist  that  the  one  disease  owed. its  origin  to  the  other. 

The  pathological  evidence  furnished  by  Dr.  Klein  lends 
strong  support  to  the  view  that  the  Hendon  cow  disease  and 
scarlet  fever  are  intimately  related  to  each  other.  A  bacterial 
organism  was  found  in  the  material  from  the  ulcerated  udders 
of  the  sick  cows,  which  presents  similar  characters  to  a  micro- 
coccus  found  by  the  same  observer  in  the  blood  of  scarlet-fever 
patients.  These  results  require  more  extended  investigations 
before  they  can  be  unreservedly  accepted. 

The  milk  of  cows  fed  upon  the  refuse  of  breweries  and  dis- 
tilleries— "  swill-milk " — is  believed  by  many  physicians  to  be 
unwholesome.  If  so,  it  is,  probably,  only  by  reason  of  the  un- 
favorable hygienic  conditions  under  which  the  animals  are  kept. 
If  the  stables  are  clean,  dry,  and  well  ventilated,  and  the  ani- 
mals receive  plenty  of  fresh  air  and  exercise,  swill-fed  cows 


100  TEXT-BOOK   OF   HYGIENE. 

should  produce  as  nutritious  milk  as  when  they  are  fed  upon 
different  food.  Much  of  the  present  agitation  against  "swill- 
milk"  is  more  prompted  by  political  demagogism  than  by 
scientific  knowledge. 

The  milk  of  animals  suffering  from  certain  diseases  is  often 
dangerous  to  health.  In  some  of  the  Western  and  Southern 
United  States,  cows  are  not  infrequently  attacked  by  an  acute 
febrile  disease  called  "  the  trembles,"  from  one  of  the  prominent 
symptoms.  The  milk  of  cows  suffering  from  this  disease  pro- 
duces severe  gastro-iritestinal  disorder,  collapse,  fever,  etc.,  in 
the  consumer.  This  disease,  called  "milk-sickness,"  is  fatal  in 
a  pretty  large  proportion  of  cases.  It  is  said  that  the  flesh  of 
animals  with  "the  trembles"  will,  if  eaten,  produce  similar  dan- 
gerous effects.  A  late  writer  (Dr.  Beach,  of  Ohio)  estimates 
that  25  per  cent,  of  the  Western  pioneers  and  their  families 
died  of  this  disease. 

For  the  ready  determination  of  the  quality  of  milk,  instru- 
ments known  as  lactoscopes,  lactometers,  and  creamometers  are 
used.  The  lactoscope  indicates  the  opacity  of  the  milk,  upon 
which  the  proportion  of  cream  depends.  One  convenient  mod- 
ification of  the  lactoscope  is  the  little  instrument  termed  the 
pioscope.  This  consists  of  a  disk  about  6|  centimetres  in  diam- 
eter, with  a  slight  depression  in  the  centre.  A  little  milk  is 
placed  in  the  depression  and  covered  with  a  glass  disk,  clear 
in  the  centre  and  opaque  around  the  border,  which  is  divided 
into  six  divisions  of  different  shades,  varying  from  white  to 
dark  gray.  The  quality  of  the  milk  is  marked  upon  the 
division  whose  color  corresponds  with  that  of  the  milk  in 
the  centre. 

A  better,  but  still  not  very  accurate,  indicator  of  the  quality 
of  the  milk  is  the  creamometer.  This  consists  of  a  cylindrical 
glass  vessel  with  the  upper  half  divided  up  into  hundredths. 
The  glass  is  filled  up  to  the  zero  mark  with  milk,  and  allowed 
to  stand  until  all  the  cream  has  separated.  The  thickness  of 
this  layer  is  then  read  off  on  the  scale.  In  Chevallier's  instru- 


FOODS   OP   ANIMAL   ORIGIN. 


101 


ment,  10  per  cent,  of  cream  is  the  minimum  proportion  that 
should  be  furnished  by  the  milk. 

The  specific  gravity,  which  is  a  fair  guide  to  the  quality  of 
the  milk,  with  the  reservations  above  mentioned,  is  measured  by 
means  of  the  lactometer  or  lactodensimeter.  The  specific 
gravity  of  good  cows'  milk  should  not  be  less  than  1029. 

In  order  to  prevent  the  rapid  fermentation  of  milk  various 
methods  of  preservation  have  been  adopted.  The  addition  of 
alkalies,  or  antiseptics,  retards  the  lactic-acid  fermentation,  while 
the  abstraction  of  a  portion  of 
the  water  and  addition  of  sugar 
(condensed  milk)  preserves  it 
for  an  indefinite  time.  The 
mere  addition  of  water  restores 
it  to  nearly  its  original  condition. 

Tyrotoxicon  in  Milk. — This 
substance,  first  found  in  poison- 
ous cheese,  and  later  in  milk,  ice- 
cream, custards,  etc.,  is  believed 
by  Professor  Vaughan  to  be  the 
cause  of  true  cholera  infantum, 
and  many  of  the  clinical  phe- 
nomena of  this  disease  lend 
strong  support  to  such  a*  view. 
The  conditions  under  which  the 
poison  is  developed  have  not  yet 
been  sufficiently  studied  to  enable  correct  conclusions  to  be  drawn. 

Butter. — Butter  is  of  especial  value  as  food  on  account  of 
the  large  amount  of  easily  digestible  fat  which  it  contains.  It  is 
almost  always  used  as  accessory  to  other  articles  of  food,  to  ren- 
der them  more  palatable.  When  pure  and  fresh,  it  is  one  of  the 
most  delicious  of  creature  comforts.  It  soon  undergoes  the 
butyric-acid  fermentation,  however,  becoming  "  rancid,"  as  it  is 
termed,  when  it  is  unfit  for  food. 

The  great  demand  for  butter  and  its  consequent  high  price 


FIG.  3. — CHEVALLIKR'S  CREAMOMETER. 


102  TEXT-BOOK   OF   HYGIENE. 

have  led  to  its  extensive  sophistication.  Butter  is  now  very 
largely  substituted  by  an  artificial  product  termed  oleo-margarine, 
or  butterine.  This  artificial  butter  is  made  from  beef-suet  by  the 
following  process :  Fresh  beef-fat  is  melted  at  as  low  a  temperature 
as  possible,  never  higher  than  52°  to  53°  C.  [126°  to  128°  F.]. 
All  membrane  and  tissue  are  then  removed,  and  the  resulting 
clear  fat  is  put  into  presses,  where  the  stearine  is  extracted. 
The  liquid  fat,  free  from  tissue,  and  with  nearly  all  its  stearine 
removed,  is  known  as  "oleo-margarine  oil."  The  next  step 
in  the  process  is  "  churning."  The  oil  is  allowed  to  run  into 
churns  containing  milk  and  a  small  quantity  of  coloring 
material  (annatto),  where,  by  means  of  rapidly-revolving  pad- 
dles, it  is  churned  for  about  an  hour.  When  this  part  of  the 
process  is  complete,  the  substance  is  drawn  off  from  the 
bottom  of  the  churn  into  cracked  ice.  When  cool  it  is  taken 
from  the  ice,  mixed  with  a  proper  quantity  of  salt,  and  is  then 
worked  like  butter  and  put  into  firkins  for  the  market.  It  is 
also  molded  into  attractive  prints  in  imitation  of  dairy-butter.1 
When  the  materials  from  which  oleo-margarine  is  made  are 
sweet  and  clean,  and  when  the  process  of  manufacture  is  prop- 
erly conducted,  the  resulting  product  is  an  entirely  harmless 
article,  and  probably  differs  very  little  in  nutritive  value  from 
butter  itself. 

Cheese. — The  value  of  cheese  as  a  food  depends  upon  the 
large  amount  of  proteids  and  fat  which  it  contains.  The  rich 
varieties  of  cheese,  such  as  Fromage  de  Brie  and  Roquefort,  con- 
tain on  an  average  35  per  cent,  of  fat  and  27  per  cent,  of  proteid 
compounds.  Parmesan  contains  only  about  18  per  cent,  of  fat 
and  nearly  40  per  cent,  of  proteids,  while  Edam  and  Cheshire 
cheese,  which  may  be  considered  as  standing  about  midway 
between  the  above,  contain  30  per  cent,  of  fat  and  nearly  28 
per  cent,  of  proteids.  From  these  figures  it  appears  that  cheese 
is  one  of  the  most  nutritious  aliments  obtainable,  but  it  cannot 

1  Dr.  W.  K.  Newton,  Fifth  Annual  Report  of  the  State  Board  of  Health  of  New  Jersey, 
1881,  p.  107. 


FOODS   OF   ANIMAL    ORIGIN. 


103 


be  eaten  in  large  quantities  at  a  time,  as  it  is  exceedingly  liable 
to  cause  disturbances  of  the  digestive  organs.  The  constipating 
property  of  cheese  is  well  known  to  the  public. 

The  relative  value  of  different  kinds  of  cheese  in  alimentary 
principles  is  given  in  the  following  table: — 

TABLE  XL 


KIND  OF  CHEESE. 

Proteids 
(per  cent.). 

Fats 
(per  cent.). 

Sugar 
(per  cent.). 

Salts 
(percent.). 

Cheshire    

27.68 

27.46 

5.89 

5.01 

Edam    

24.07 

30.26 

4.48 

4.91 

29.48 

26.71 

2.27 

4  62 

27.69 

33.44 

3.15 

5.35 

Neufchatel      

17.44 

40.80 

5.21 

2.05 

Parmesan  

41.19 

19.52 

1.18 

6.31 

Cheese  is  not  often  adulterated.  The  only  articles  used 
with  success  in  its  sophistication  are  lard  and  oleo-margarine, 
which  are  incorporated  with  the  casein  during  the  process  of 
manufacture.  It  sometimes  undergoes  chemical  changes  which 
render  it  intensely  poisonous  when  eaten. 

Prof.  V.  C.  Vaughan,  of  the  University  of  Michigan,  has 
ascertained  that  the  substance  causing  the  poisonous  symptoms 
is  a  chemical  compound  termed  by  him  tyrotoxicon.  This 
same  poison  has  also  been  found  by  Professor  Vaughan  and 
other  chemists  in  ice-cream  and  fresh  milk,  which  produced 
poisonous  symptoms  when  consumed.  The  poison  is  supposed 
to  be  a  ptomaine  produced  by  the  agency  of  a  micro-organism, 
which  has,  however,  not  yet  been  isolated. 

Meat. — The  flesh  of  mammals,  reptiles,  birds,  fish,  and 
invertebrate  animals  is  used  as  food  by  man.  Falck1  has  classi- 
fied the  varieties  of  animals  which  furnish  food  to  the  inhabitants 
of  Europe.  There  are  47  varieties  of  the  mammalian  class, 
105  of  birds,  7  of  amphibia,  110  of  fish,  and  58  of  invertebrates. 

1  Das  Fleisch,  Gemeinversteendliches  Handbuch  der  Wissenschaf  tlichen  und  Praktischen 
Fleisclikunde. 


104 


TEXT-BOOK   OF    HYGIENE. 


Meat  is  the  most  important  source  of  proteids  in  the  food. 
In  the  more  commonly  used  varieties  of  meat  the  proteids  and 
fats  constitute  from  25  to  50  per  cent,  of  the  entire  bulk,  the 
proportion  depending  largely  upon  the  age  of  the  animal  and  its 
bodily  condition.  The  following  table  shows  the  influence  of 
these  two  factors  upon  the  relative  proportions  of  the  fats  and 
proteids  contained  in  the  meat: — 

TABLE  XII.1 


Proteids  (percent.). 

Fats  (per  cent.). 

Moderately  fat  beef     

21.39 

5.19 

Lean  beef  

20.54 

1.78 

Veal  

10.88 

7.41 

VervT  fat  mutton 

14.80 

36.39 

«/ 

Fat  pork     

14.54 

37.34 

Lean  pork  

19.91 

6.81 

Hare  

23.34 

1.13 

Lean  chicken  

19.72 

1.42 

The  flesh  of  animals,  which  is  neutral  in  reaction  immedi- 
ately after  death,  soon  becomes  acid  in  consequence  of  the 
formation  of  lactic  acid.  The  acid,  acting  upon  the  sarcolemma 
and  the  muscular  fibre,  renders  it  softer  and  more  easily  per- 
meable by  fluids  when  cooking,  and  more  susceptible  to  the 
action  of  the  gastric  juice  when  the  meat  is  taken  into  the 
stomach. 

Certain  kinds  of  meat — mutton  and  venison,  for  example — 
are  often  kept  so  long  before  being  eaten  that  a  considerable 
degree  of  putrefaction  has  taken  place  when  they  are  brought 
upon  the  table.  The  wisdom  of  this  practice  is  questionable 
from  a  hygienic  point  of  view. 

Meat  is  sometimes  eaten  raw,  but  it  is  usually  first  cooked. 
The  methods  of  cooking  in  general  use  are  boiling,  frying, 
roasting,  broiling,  and  baking.  By  either  of  these  methods  of 

'Abridged  from  Loebisch ;  article  "Fleisch"  in  Realencyclopjedie  d.  ges.  Heilkunde, 
vol.  v,  p.  340.  Fuller  details  will  be  found  in  Table  VIII. 


FOODS   OF   ANIMAL   ORIGIN.  105 

cooking,  when  properly  carried  out,  the  nutritious  properties  of 
the  meat  are  preserved,  and  it  is  rendered  digestible.  The 
culinary  art  deserves  the  closest  attention  of  students  of  hygiene. 

A  number  of  soluble  preparations  of  meat  (beef-extract, 
beef-essence,  beef-juice)  are  found  in  the  market,  and  highly 
recommended  as  containing  all  the  nutritious  qualities  of  the 
meat  from  which  they  are  prepared.  These,  and  similar  products 
of  domestic  preparation  (broths  and  teas),  contain  in  reality 
very  little  nutritive  material,  but  are  of  use  almost  solely  as 
stimulants  to  the  appetite  and  digestion.  They  have  a  place  in 
the  dietary  of  the  sick,  but  their  nutritive  value  is» small. 

On  the  other  hand,  a  number  of  partly  or  wholly  predi- 
gested  (peptonized  or  pancreatized)  preparations  of  meat  are 
offered  for  sale,  many  of  which  have  a  high  nutritive  value. 
They  cannot,  however,  be  used  as  articles  of  diet  except  for  a 
short  time,  or  as  a  temporary  succedaneum  for  meat  in  diseases 
attended  with  weakness  or  derangement  of  the  digestive  organs. 

Meat  may  be  unfit  for  food  from  various  causes.  Thus 
the  flesh  of  animals  dying  from  certain  diseases — splenic  fever, 
pleuro-  pneumonia,  tuberculosis  in  its  advanced  stages,  cow-  or 
sheep-  pox — should  not  be  used  as  food  when  it  can  be  avoided. 
Cases  are  on  record  proving  the  poisonous  character  of  meat 
from  animals  which  suffered,  at  the  time  of  death,  from  some  of 
the  above-mentioned  diseases.  The  most  important  condition 
to  be  borne  in  mind  is  that  certain  parasites  (trichina  spiralis, 
echinococcus,  cysticercus),  which  frequently  infest  the  flesh  of 
animals,  especially  hogs,  not  infrequently  give  rise  to  serious  or 
even  fatal  diseases  in  persons  consuming  such  meat.  Any  meat 
containing  these  parasites,  or  suspected  of  containing  them, 
should  therefore  not  be  used  as  food  unless  precautions  be  first 
taken  to  destroy  the  life  of  the  parasite. 

Of  the  parasites  mentioned  the  trichina  spiralis  is  the  most 
important  in  this  connection,  as  it  frequently  occurs  in  the  flesh 
of  hogs,  rats,  dogs,  cats,  and  other  carnivorous  animals.  Rats 
are  said  to  be  infested  with  the  parasite  more  frequently  than 


106  TEXT-BOOK   OF   HYGIENE. 

any  other  animals.  The  trichinae  are  found  in  two  forms,  one, 
the  mature  form,  inhabiting  the  intestinal  canal.  The  immature 
form,  or  muscle  trichinae,  are  found  in  striped  muscle,  coiled  into 
spirals  and  encysted  in  a  fibrous  capsule.  They  gain  access  to 
their  host  in  the  following  manner:  Flesh  containing  living 
trichinae  is  taken  into  the  stomach,  where  the  muscular  tissue 
and  the  fibrous  envelope  are  dissolved,  and  the  inclosed  worms 
set  free.  These  mature  in  the  intestinal  canal,  where  sexual 
reproduction  takes  place,  and  the  young  embryos  pass  through 
the  intestinal  walls  and  other  tissues  until  they  become  imbedded 
in  striated  muscle.  Localized  epidemics  of  trichinosis  have 
been  reported  in  this  country  and  Europe,  and  in  nearly  every 
instance  the  source  of  the  disease  has  been  traced  to  the  inges- 
tion  of  uncooked  pork.  Meat  known  to  be  trichinous  should 
not  be  used  unless  in  times  of  great  scarcity.  It  may,  however, 
be  rendered  innocuous  by  thorough  cooking.  .  A  temperature 
of  60°  to  70°  (140°  to  160°  F.)  destroys  the  life  of  the  parasite 
and  renders  the  meat  safe.  On  account  of  the  frequent  occur- 
rence of  trichinae  in  pork,  this  meat  should  never  be  eaten  unless 
thoroughly  cooked.  It  has  been  ascertained  that  salted  and 
smoked  pork  is  not  free  from  danger,  as  the  parasites  are  not 
killed  in  the  process  of  curing  the  meat.  Hence,  ham  and 
sausage  should  not  be  eaten  raw,  as  the  danger  from  these 
articles  is  almost  equally  as  great  as  from  fresh  pork. 

Cysticercus  cellulosa^  the  transition  form  of  one  variety  of 
tape-worm,  and  which  is  the  parasite  in  measly  pork,  may  also 
gain  entrance  to  the  human  body,  and,  failing  to  undergo  devel- 
opment, cause  very  serious  lesions  of  various  organs  and  tissues. 
The  frequency  of  tape-worm  is  evidence  that  pork  is  often  thus 
diseased. 

The  use  of  partially  decayed  meat  or  fish  has  often  been 
the  cause  of  serious  or  fatal  illness.  Sometimes  the  illness  par- 
takes of  the  character  of  septic  infection.  In  these  cases  it  is 
probable  that  the  morbid  process  is  due  to  the  action  of  the 
organisms  of  putrefaction.  In  other  cases  the  symptoms  are 


FOODS  OF   ANIMAL   ORIGIN.  107 

widely  different.  These  cases  have  been  the  source  of  much 
perplexity  to  physicians  and  toxicologists  until  very  recently. 
Within  the  past  six  years,  however,  Selmi,  Husemann,  Brouardel, 
Casali,  and  others  have  drawn  attention  to  certain  intensely 
poisonous  chemical  compounds  found  in  decomposing  flesh,  and 
which  have  been  named  by  Selmi  ptomaines.  While  there  is 
still  much  uncertainty  concerning  the  nature  of  these  compounds, 
it  seems  pretty  well  established  that  when  flesh  undergoes  de- 
composition, in  the  absence  of  oxygen,  certain  unstable  chemical 
combinations  are  formed  which  act  as  violent  poisons.  Selmi, 
followed  by  most  toxicologists,  believes  these  compounds  to  be 
alkaloids,  analogous  to  the  vegetable  alkaloids,  such  as  morphine, 
atropine,  etc.  Casali,  on  the  other  hand,  disagrees  with  this 
opinion,  and  believes  the  ptomaines  to  be  amido  compounds. 
Husemann  regards  Casali's  hypothesis  as  plausible,  inasmuch  as 
the  formation  of  amido  compounds  in  animal  and  vegetable 
bodies  during  decomposition  is  well  established. 

The  form  of  poisoning  due  to  the  organisms  of  putrefaction 
is  not  infrequent.  An  extensive  outbreak  of  this  nature  occurred 
at  Andelfingen,  in  Switzerland,  in  1839.  A  musical  festival 
was  held,  at  which  there  were  over  700  present.  Out  of  these 
444  were  suddenly  attacked  by  violent  gastro-enteric  and  nervous 
symptoms.  Ten  of  the  patients  died.  The  illness  was  traced  to 
roast  veal,  which  had  been  kept  in  a  warm  place  for  two  days 
after  roasting,  and  which  was  probably  in  a  state  of  partial 
decomposition. 

The  class  of  cases  which  seem  more  probably  due  to  the 
action  of  ptomaines  or  related  poisons,  have  been  frequently 
observed  after  eating  sausages  or  canned  meats.  Sausage  poi- 
soning is  not  rarely  observed  in  Germany.  It  has  been  ascer- 
tained that  the  internal  portions  of  the  sausage  are  the  most 
poisonous.  It  is  supposed  that  the  ptomaines,  which  are  formed 
in  the  absence  of  oxygen,  are  the  active  agents  in  the  pro- 
duction of  the  train  of  symptoms.  Poisoning  by  canned  meat 
seems  to  be  due  to  a  similar  poison. 


108  TEXT-BOOK   OF   HYGIENE. 

In  July,  1885,  an  outbreak  of  disease,  due  to  eating  un- 
wholesome beef,  was  caused  at  Momence,  Illinois.  Chemical 
examination  of  specimens  of  the  meat  showed  the  presence  of 
an  alkaloidal  body,  which  was  believed  to  be  a  ptomaine,  but  its 
nature  was  not  definitely  determined. 

Fish,  oysters,  crabs,  and  lobsters  frequently  give  rise  to 
symptoms  of  poisoning.  In  most  of  these  cases  the  poisoning 
is  probably  due  to  partial  decomposition,  but  it  is  a  well-known 
fact  that  oysters  and  crabs  are  unfit  for  food  at  certain  seasons. 
Some  persons,  however,  are  subjects  of  a  peculiar  idiosyncrasy, 
in  consequence  of  which  shell-fish  always  produce  certain  un- 
pleasant symptoms,  among  which  nettle-rash  and  a  choleraic 
attack  are  most  prominent. 

That  form  of  fish-poisoning  known  among  the  Spaniards 
in  the  West  Indies  as  siguatera  is,  however,  very  grave.  The 
mortality  is  large,  and  in  many  cases  death  succeeds  rapidly 
upon  the  attack.  The  symptoms  are  as  follow:  Sometimes 
suddenly,  sometimes  preceded  by  dizziness  and  indistinct  vision, 
great  prostration  and  paralysis  occur.  Often  death  follows  the 
onset  of  the  symptoms  in  two  and  three  hours ;  exceptionally  in 
less  than  twenty  minutes.  In  most  cases  consciousness  is  totally 
lost;  in  others  it  persists,  with  interruptions,  until  death.  Sensa- 
tion and  the  powers  of  speech  and  deglutition  fail.  The  jaw- 
muscles  become  paralyzed,  the  pulse  is  slowed,  and  the  tem- 
perature diminished.  There  is  sometimes  vomiting,  but  no 
purging.  The  secretion  of  the  kidneys  is  also  checked.  Dr. 
McSherry  states1  that  he  has  seen  all  these  symptoms  produced 
by  eating  oysters,  lobsters,  and  crabs  unseasonably. 

In  Russia  a  form  of  poisoning  has  often  been  observed 
which  results  from  eating  salted  sturgeon.  In  the  fresh  state 
these  fish  are  perfectly  wholesome,  but  when  salted  and  eaten 
raw  they  produce  a  very  fatal  illness.  The  mortality  is  said  to 
reach  50  per  cent,  of  those  attacked.  No  cases  traceable  to 
this  cause  have  been  observed  in  this  country. 

1  Health  and  How  to  Promote  it,  p.  143. 


FOODS   OF    ANIMAL   ORIGIN.  109 

It  has  been  shown,  beyond  question,  that  the  flesh  of  beeves 
suffering,  when  killed,  from  splenic  fever,  will  produce  this 
disease  in  the  human  subject. 

In  1874  an  extensive  and  violent  outbreak  of  an  acute 
disease,  characterized  by  vomiting  and  purging,  fever  and  dizzi- 
ness, occurred  at  Middelburg,  in  Holland.  Three  hundred  and 
forty-nine  persons  were  attacked,  of  whom  6  died.  The  out- 
break was  traced  to  eating  liver-sausage  (Leberwurst),  in  which 
the  characteristic  bacillus  of  splenic  fever  was  found  on  micro- 
scopic examination.  In  July,  1877,  an  outbreak  of  choleraic 
disease,  from  eating  carbuncular  meat,  occurred  in  the  town  of 
Wurzen.  In  the  latter  epidemic  the  bacillus  of  splenic  fever 
{Bacillus  antJiracis)  was  found  in  the  intestinal  canal  and  in  the 
blood  of  those  attacked. 

In  Detmold,  in  Germany,  an  outbreak  of  violent  gastro- 
intestinal inflammation,  accompanied  by  high  fever,  occurred. 
Among  the  150  persons  attacked  3  died.  The  disease  was 
traced  to  eating  the  meat  of  a  cow  suffering,  before  death, 
from  pleurisy  (probably  pleuro-pneumonia).  In  view  of  the 
somewhat  extensive  prevalence  of  this  disease  among  cattle  in 
this  country  at  the  present  time,  the  record  of  this  outbreak  may 
suggest  to  sanitary  authorities  some  measures  for  the  prevention 
of  similar  epidemics  on  this  side  of  the  Atlantic. 

In  July,  1880,  72  persons  who  had  eaten  of  certain  beef 
and  ham-sandwiches  in  Welbeck,  England,  were  attacked  by 
choleraic  diarrhoea;  4  of  the  cases  died.  Inflammation  of  the 
lungs  and  small  intestines  were  the  most  prominent  pathological 
conditions  found  post-mortem.  The  smaller  blood-vessels  of  the 
kidneys  were  filled  with  finger-shaped  bacilli,  which,  when  cul- 
tivated and  inoculated  into  guinea-pigs,  rats,  and  white  mice, 
produced  similar  pathological  conditions.  At  Nottingham, 
England,  in  1881,  a  number  of  persons  were  attacked  by  a 
similar  train  of  symptoms  after  eating  baked  pork.  One  case 
terminated  fatally  out  of  the  15  attacked.  It  is  uncertain 
whether  the  meat  in  these  two  instances  was  from  diseased 


110  TEXT-BOOK   OF    HYGIENE. 

animals  or  whether  it  had  undergone  partial  decomposition. 
The  former  is  the  more  probable  supposition,  although  the 
organisms  found  were  neither  those  of  splenic  fever  nor  swine 
plague,  but  resembled  those  of  symptomatic  anthrax  (black  leg 
or  black  quarter). 

Whether  the  flesh  of  tuberculous  animals  can  communicate 
tuberculosis  to  the  consumer  is  still  an  unsettled  question. 
Foreign  veterinarians  and  hygienists  who  have  studied  the 
question  incline  to  the  view  that  there  is  danger  of  such  trans- 
mission. At  the  International  Sanitary  Congress  of  1883,  at 
Brussels,  the  subject  was  discussed,  and  M.  Lydtin,  the  chief 
veterinary  surgeon  of  the  Grand  Duchy  of  Baden,  submitted 
the  following  propositions,  which  were  adopted  by  the  Congress : 

1.  That  the  flesh  and  viscera  of  tuberculous  animals  may 
be  used  as  food,  provided  the  disease  is  only  commencing,  the 
lesions  extending  but  to  a  small  part  of  the  body,  the  lymphatic 
glands  being  still  healthy;  provided  the  tubercle  centres  have 
not  undergone  softening,  and  provided  the  carcass  is  well  nour- 
ished and  the  flesh  presents  the  characters  of  meat  of  the  first 
quality.  2.  That  the  flesh  of  animals  showing  very  pronounced 
tuberculous  infection  should  be  saturated  with  petroleum,  and 
afterward  burned  under  the  direction  of  the  police.  3.  That  the 
milk  from  cows  affected  with  pulmonary  phthisis,  or  suspected  of 
having  it,  should  not  be  consumed  by  man  or  other  animals, 
and  the  sale  of  it  should  be  strictly  prohibited. 

The  congress  for  the  study  of  tuberculosis,  which  met  in 
Paris  in  1888,  adopted  resolutions  of  a  more  decided  character 
against  the  use  of  meat  and  milk  from  tuberculous  animals. 

Certain  animals  can  devour  with  impunity  substances 
which  are  intensely  poisonous  to  human  beings.  The  flesh  of 
the  animals  may  be  impregnated  with  these  poisons,  and  cause 
serious  and  fatal  illness  in  persons  partaking  of  it.  In  this  way 
may,  perhaps,  be  explained  the  cases  of  poisoning  sometimes 
following  the  eating  of  partridges  and  other  birds. 

The  prevention  of  disease   from  tainted  meat  is  one  of  the 


FOODS   OF    ANIMAL    ORIGIN.  Ill 

most  important  problems  of  public  hygiene.  Food  animals 
should  be  inspected  by  qualified  inspectors  before  slaughtering, 
to  exclude  animals  suffering  from  diseases  that  would  vitiate  the 
meat.  When  the  meat  is  exposed  for  sale  upon  the  dealer's 
stall  it  should  be  again  inspected,  and  all  found  unfit  for  use  as 
food  confiscated  and  destroyed.  Meat,  in  which  the  presence 
of  trichina?  or  other  parasites  is  suspected,  should  be  examined 
microscopically.1 

Eggs. — Although  eggs  contain  a  large  amount  of  the  pro- 
teid  and  fatty  alimentary  principles,2  their  value  as  food  has 
probably  been  greatly  overrated.  The  savory  taste  and  ready 
digestibility  of  eggs  has,  however,  rendered  them  a  popular 
article  of  food.  For  obvious  reasons,  the  eggs  of  the  common 
barn-yard  fowl  are  most  frequently  used,  those  of  ducks  and 
geese  being  far  inferior  in  flavor  to  the  first  named,  and  being 
likewise  less  easily  obtained. 

The  method  of  cooking  eggs  is  generally  supposed  to  have 
considerable  influence  upon  their  digestibility.  According  to 
Dr.  Beaumont's  experiments  made  on  Alexis  St.  Martin,  raw 
eggs  are  digested  in  one  and  a  half  to  two  hours,  fresh-roasted 
in  two  hours  and  fifteen  minutes,  soft-boiled  or  poached  in  three 
hours,  and  hard-boiled  or  fried  in  three  and  a  half  hours.  These 
experiments  are,  however,  of  very  little  value  as  a  basis  for 
general  conclusions.  It  is  probable  that  a  hard-boiled  egg  is 
quite  as  easily  digested  in  the  healthy  stomach  as  a  raw  one,  if 
care  be  taken  to  masticate  it  well  and  eat  bread  with  it,  so  that 
it  is  introduced  into  the  stomach  in  a  finely-divided  state. 

Eggs  readily  undergo  putrefaction,  when  sulphuretted 
hydrogen  is  formed  in  them  in  large  quantities.  When  this 
has  taken  place  they  are  manifestly  unfit  to  be  used  as  food. 

1  The  prevention  of  the  diseases  of  animals  by  National  and  State  authorities  is  one  of 
the  most  logical  and  thorough-going  means  of  preventing  disease  from  unwholesome  meat.  The 
American  Public  Health  Association  has  for  some  years  devoted  considerable  attention  to  the 
investigation  of  the  diseases  of  animals  and  means  for  their  prevention.  The  Department  of 
the  Interior  of  the  National  Government  has  likewise  made  the  diseases  of  cattle  and  hogs  a 
subject  of  study  and  published  some  valuable  reports  thereon. 

»  See  analysis  in  Table  VIII. 


112  TEXT-BOOK   OF   HYGIENE. 

FOODS   OF   VEGETABLE   ORIGIN. 

Bread. — The  various  cereal  grains,  when  ground  into  flour, 
are  used  in  making  bread.  The  flours  of  wheat,  rye,  barley, 
buckwheat,  and  Indian  corn  are  almost  exclusively  used  in  bread- 
making.  The  bran  or  cortical  portion  of  grain  contains  a  larger 
percentage  of  proteid  principles  than  the  white  internal  portion ; 
hence,  flours  made  from  the  whole  grain  (bran-flour,  Graham 
flour)  if  finely  ground  are  more  nutritious  than  the  white  flours. 
The  latter  are,  however,  more  digestible,  and  hence  furnish  a 
larger  proportion  of  nutriment,  because  the  principles  contained 
in  white  flours  are  absorbed  and  assimilated  to  a  greater  degree. 

Good  bread  should  be  light,  porous,  and  well  baked.  The 
lightness  and  porosity  are  due  to  carbon-dioxide  gas  imprisoned 
in  cavities  of  the  dough  during  the  process  of  bread-making. 
By  adding  yeast  to  the  dough  a  fermentation  is  caused  in  the 
latter,  in  consequence  of  which  a  portion  of  the  starch  is  con- 
verted into  sugar,  and  then  into  alcohol  and  carbon  dioxide. 
During  the  process  of  mixing  the  dough  the  entire  mass  becomes 
permeated  by  the  gas,  which,  on  heating,  expands  and  leaves 
the  numerous  large  and  small  cavities  throughout  the  loaf  which 
indicate  properly-made  bread. 

Instead  of  yeast  some  persons  use  leaven,  which  is  simply 
a  portion  of  fermenting  dough,  saved  from  previous  baking.  A 
small  quantity  of  this  added  to  a  mass  of  dough  starts  up  the 
fermentation  in  a  similar  manner  to  that  of  yeast. 

The  production  of  carbon  dioxide  by  fermentation  in  the 
dough  goes  on  at  the  expense  of  part  of  the  starch.  It  has 
been  proposed,  therefore,  to  supply  the  carbon  dioxide  from 
without,  thus  saving  the  entire  amount  of  the  carbohydrates 
present  in  the  flour.  This  is  accomplished  in  two  ways — 
first,  by  the  use  df  some  alkaline  carbonate  or  bicarbonate 
(bicarbonate  of  sodium,  carbonate  of  ammonium),  the  carbon 
dioxide  being  set  free  on  the  application  of  heat ;  or,  secondly, 
by  forcing  the  gas,  previously  prepared,  into  the  dough  by  means 
of  machinery. 


FOODS   OF   VEGETABLE   ORIGIN. 


113 


Flour  is  not  infrequently  adulterated  with  chalk,  gypsum, 
pipe-clay,  and  similar  articles.  These  are  easily  detected  by 
adding  a  mineral  acid,  which  produces  effervescence  when  it 
comes  in  contact  with  the  alkaline  carbonate  used  as  adulterant. 
Potato-  and  bean-  meals  are  also  used  as  adulterants  of  the  higher 
grades  of  flour.  Bakers  often  mix  alum  with  inferior  grades  of 
flour.  This  imparts  a  greater  degree  of  whiteness  to  the  bread, 
and,  in  addition,  enables  it  to  retain  a  large  proportion  of  water, 
thereby  increasing  the  weight  of  the  loaf. 

Formerly  diseased  grain  (ergotized  rye)  often  caused  out- 
breaks of  disease  when  the  flour  made  from  the  diseased  grain 
was  used  in  bread-making.  At  the  present  time  such  accidents 
rarely  occur.  In  some  parts  of  Italy  it  is  said  that  an  endemic 
disease — pellagra — is  caused  by  the  consumption  of  diseased 
Indian  corn.  The  evidence  in  favor  of  this  view  is,  however, 
not  unquestioned. 

Potatoes  and  rice  are  often  used  with  satisfaction  as  substi- 
tutes for  bread.  They  both  contain  a  large  proportion  of  carbo- 
hydrates. Indian  corn  (hominy)  and  oatmeal  are  likewise 
wholesome  and  nutritious  foods  of  this  class. 

The  leguminous  seeds  (beans,  peas,  lentils)  furnish  a  food 
containing  a  large  percentage  of  proteids.  According  to  the 
analyses  of  Kcenig l  the  average  composition  of  the  most  fre- 
quently used  legumes  in  the  dried  condition  is  as  follows : — 

TABLE  XIII. 


Beans. 

Peas. 

Lentils. 

;Ground-nuts.* 

Water,  per  cent.  .  .  . 
Solids,  per  cent.  .  .  . 

13.6 

86.4 

14.3 

85.7 

12.5 

87.5 

6.5 
93.5 

Proteids,  per  cent.  .  . 
Fats  

23.1 
2.3 

53.6 
3.9 
3.5 

22.6 
1.7 
53.2 
5.5 

2.7 

24.8 
1.9 
54.7) 
3.6) 
2.5 

28.2 
46.4 

15.7 
3.2 

Carbohydrates,  per  cent. 
Cellulose,  per  cent.  .  . 
Ash  

1Die  Menschlicheu  Nahruugs  und  (Jenussmittel,  ii,  p.  288. 

*  The  American  pea-nut,  the  fruit  or  nut  of  Arachis  hypogcea. 


114  TEXT-BOOK   OF   HYGIENE. 

Beans,  peas,  and  lentils  are  often  added  to  other  articles  of 
food  with  advantage.  In  recent  years  an  important  article  of 
food  for  armies  has  been  made  of  various  legumes  ground  into 
flour  and  mixed  with  fat,  dried  and  powdered  meat,  salt,  and 
spice.  This  constitutes  the  so-called  "  Erbswurst,"  or  pea-sausage, 
which  formed  such  an  important  part  of  the  dietary  of  the  German 
army  in  the  Franco-German  war  of  1871.  Bean-  and  pea-  meals 
are  also  used  sometimes  as  additions  to  other  flours  in  bread- 
making.  The  dried  leguminous  fruits  cannot  be  used  as  regular 
articles  of  diet,  however,  as  they  soon  pall  upon  the  taste,  and 
produce  indigestion,  nausea,  and  other  intestinal  derangements. 

Green  Vegetables. — The  plants  usually  classed  together  as 
"  vegetables,"  the  products  of  the  market-garden  or  truck-farm, 
comprise  cabbages,  turnips,  parsnips,  onions,  beets,  carrots, 
tomatoes,  lettuce,  green  peas  and  beans,  and  similar  articles. 
They  all  contain  a  large  proportion  of  water,  a  variable  propor- 
tion of  sugar,  and  a  small  percentage  of  proteid  principles. 
Much  of  their  palatability  and  digestibility  depend  upon  the 
methods  by  which  they  are  prepared  for  the  table.  All  garden 
vegetables  should  be  used  soon  after  being  gathered,  as  they 
rapidly  undergo  decomposition,  and  are  liable  to  produce 
derangements  of  the  digestive  organs  if  used  under  these 
conditions. 

Fruits  and  nuts  generally  contain  large  quantities  of  sugar 
and  fats.  They  form  agreeable  additions  to  other  articles  of 
diet,  but  are  insufficient  to  sustain  life.  The  use  of  fruits  usually 
produces  copious  intestinal  evacuations,  and  they  are,  therefore, 
especially  to  be  recommended  to  persons  of  sedentary  occupations, 
in  whom  torpidity  of  the  bowels  is  so  frequently  present. 

Condiments. — Various  aromatic  herbs  and  seeds  are  used 
as  additions  to  other  articles  of  food,  to  increase  their  sapidity 
and  to  promote  a  larger  flow  of  saliva  and  gastric  juice,  and  so 
assist  digestion.  Mustard,  pepper,  allspice,  and  vinegar  are  the 
principal  condiments.  Within  certain  limits  they  are  not  in- 
jurious, but  the  tendency  in  the  use  of  all  stimulants  is  to 


COOKING.  115 

exceed  a  healthful  limit.     Condiments,  as  well  as  other  stimu- 
lants, should  be  used  in  moderation. 

COOKING. 

Much  more  attention  than  is  generally  given  should  be  paid 
by  physicians  to  the  culinary  art.  The  manner  in  which  food  is 
cooked  has  no  little  influence  upon  its  digestibility.  There  can 
be  no  question  that  the  extreme  prevalence  of  functional  indi- 
gestion in  this  country  is  almost  exclusively  dependent  upon  bad 
cooking. 

The  various  methods  of  cooking  are  boiling,  frying,  roast- 
ing, broiling,  and  baking.  By  either  of  these  methods  food  can 
be  cooked  so  as  to  be  palatable  as  well  as  digestible ;  on  the  other 
hand,  the  choicest  article  can  be  utterly  spoiled  and  rendered 
unfit  to  be  taken  into  the  human  stomach.  It  depends,  therefore, 
not  so  much  upon  the  method  of  cooking,  as  upon  the  knowledge 
and  art  of  the  cook. 

Boiling. — Meats  of  all  kinds  are  rendered  tender  and  di- 
gestible by  boiling.  In  order  to  retain  the  flavor  of  meat,  the 
water  should  be  boiling  when  the  meat  is  put  into  it.  By  the 
heat  of  the  boiling  water  the  albumen  on  the  outside  of  the 
meat  is  coagulated  and  the  juices  and  flavor  retained  within. 
After  a  few  minutes  the  temperature  of  the  water  should  be  re- 
duced to  71°  to  77°  C.  (160°  to  170°  R),  and  maintained  at  that 
height  until  the  meat  is  tender.  By  this  process  a  much  more 
savory  piece  of  beef,  mutton,  or  fowl  can  be  obtained  than  where 
the  meat  is  put  into  cold  water  and  thus  gradually  heated.  The 
latter  method  is,  however,  the  proper  one  to  be  followed  when 
good  soup  or  broth  is  desired. 

In  boiling  vegetables,  as  much  care  is  necessary  as  in  boil- 
ing meat  or  fish.  Potatoes  and  rice  should  be  steamed,  rather 
than  boiled. 

The  difficulty  of  obtaining  a  good  cup  of  coffee,  especially 
in  the  northern  portion  of  the  United  States,  illustrates  the  pre- 
vailing ignorance  upon  one  of  the  simplest  points  in  the  art  of 


116  TEXT-BOOK   OF   HYGIENE. 

cooking.  Coffee  should  never  be  served  in  the  form  of  a  de- 
coction; that  is  to  say,  it  should  never  be  boiled.  Properly  made 
it  is  an  infusion,  like  tea,  which  no  one  ever  thinks  of  boiling. 
The  difference  between  an  infusion  (especially  if  made  by  per- 
colation) and  a  decoction  of  coffee  can  only  be  appreciated  by 
those  who  have  enjoyed  the  one  and  endured  the  other. 

Frying. — Frying,  if  properly  done,  is  really  nothing  less 
nor  more  than  boiling  in  oil  or  fluid  fat  of  some  kind.  Olive- 
oil  is  preferable,  but  is  not  essential ;  butter,  beef-drippings,  lard, 
or  probably  cotton-seed  oil  may  be  substituted  for  it  without 
disadvantage.  The  principle  of  frying  depends  upon  the  fact 
that  the  temperature  of  oil  can  be  raised  to  such  a  height  as  to 
produce  instant  coagulation  of  the  surface  of  meat,  fish,  or  other 
object  immersed  in  it  while  hot ;  this  film  of  coagulated  albu- 
men imprisons  the  juices  and  flavors  of  the  meat  or  fish,  and  pre- 
vents the  fat  entering  and  soaking  the  fibres  with  grease.  Small 
fish  or  birds,  properly  fried,  are  justly  regarded  as  delicacies  by 
connoisseurs,  but  the  process  of  saturating  these  objects  with  fat 
while  gradually  heating  them  produces  a  dish  that  is  anything 
rather  than  grateful  to  the  palate,  or  conducive  to  good  digestion. 

Roasting. — The  fame  of  "  the  roast  beef  of  Old  England  " 
has  passed  into  song,  but,  at  the  present  day,  beef  and  other 
meats  are  rarely  roasted,  either  in  this  country  or  abroad.  As 
Sir  Henry  Thompson  well  expresses  it,1  "the  joint,  which  for- 
merly turned  in  a  current  of  fresh  air  before  a  well-made  fire,  is 
now  half  stifled  in  a  close  atmosphere  of  its  own  vapors,  very 
much  to  the  destruction  of  the  characteristic  flavor  of  a  roast." 
It  is  probable  that  the  old  method  of  roasting  before  an  open  fire 
produced  not  only  the  most  savory,  but  likewise  the  most  nu- 
tritious and  digestible,  meat.  It  is  much  to  be  regretted  that  the 
process  has  fallen  so  greatly  into  disuse. 

Broiling  and  Baking. — These  methods  of  cooking  are 
modifications  of  the  process  of  roasting.  Meats  or  fish,  care- 
fully broiled  or  baked,  preserve  their  natural  juices  and  flavors 

1  Food  and  Feeding,  p.  45.    London,  1880. 


ALIMENTARY  BEVERAGES.  117 

to  a  great  extent,  and  retain  their  digestibility  and  nutritious 
properties.  Of  all  methods  of  cooking  these  are  probably  best 
known  and  most  satisfactorily  applied  in  this  country.1 

ALIMENTARY   BEVERAGES. 

The  alimentary  beverages  may  be  divided  into  two  classes, 
— those  depending  for  their  effects  upon  the  alcohol  they  contain, 
and  those  whose  active  principles  reside  in  certain  alkaloids. 
They  are  used  chiefly  as  digestive  and  nervous  stimulants. 

BEVERAGES   CONTAINING   ALCOHOL. 

The  physiological  action  of  alcohol  has  been  pretty  fully 
worked  out  by  Binz  and  his  pupils,  and  by  other  experimenters. 
From  these  researches,  it  appears  that  the  first  effect  of  taking 
alcohol,  sufficiently  diluted,  into  the  stomach,  is  to  increase  the 
flow  of  the  saliva  and  gastric  juice.  This  effect  is  probably  re- 
flex, and  results  from  a  stimulation  of  nerve  terminations  in  the 
stomach.  The  alcohol  is  rapidly  absorbed,  and  is  carried  in  the 
blood,  without  undergoing  chemical  change,  to  the  nervous 
centres,  lungs,  and  tissues  generally.  In  the  brain  the  alcohol 
probably  enters  into  combination  with  the  nervous  tissue, 
modifying  the  normal  activity  of  the  various  centres,  either 
increasing  the  activity,  if  the  alcohol  is  in  small  quantity  (stim- 
ulating effect),  or  diminishing  it  if  in  larger  quantity  (depressing 
effect),  or  entirely  suspending  the  activity  of  the  centres,  if  in 
sufficiently  large  quantity  (paralyzing  effect). 

Alcohol  stimulates  the  vasodilator  nerves,  causing  dilata- 
tion of  the  smaller  vessels ;  in  consequence  of  this  the  blood  is 
largely  sent  to  the  periphery  of  the  body ;  the  blood-pressure 
diminishes,  and  heat-radiation  is  increased.  At  the  same  time 
a  portion  of  the  alcohol  is  used  up  in  the  lungs  in  the  produc- 
tion of  animal  heat,  thus  economizing  the  expenditure  of  fats 

1  Every  one  interested  in  the  proper  application  of  the  principles  of  cookery  should 
study  the  Lomb  prize  essay  of  the  American  Public  Health  Association,  by  Mary  II  in  man  Abel, 
upon  "Practical.  Sanitary,  and  Economic  Cooking."  This  little  book  can  be  obtained  of  Dr.  L 
A.  Watson,  Seeri-tary,  Concord,  N.  H. ;  price,  25  cents.  See,  also,  an  essay  on  "The  Art  of  Cook- 
ing," by  Edward  Atkinson,  L.L.D.,  in  Popular  Science  Monthly,  November,  1889. 


118  TEXT-BOOK   OF    HYGIENE. 

and  proteids,  and  acting  as  a  true  respiratory  food.  Alcohol 
does  not  contribute  nutritive  material  to  the  body ;  it  only  per- 
mits that  which  is  stored  up  to  be  saved  for  other  uses,  by  fur- 
nishing easily-oxidizable  (combustible)  material  for  carrying  on 
the  respiratory  process,  and  supplying  animal  heat. 

During  the  use  of  alcohol  the  excretion  of  urea  is  dimin- 
ished. This  shows  that  waste  of  tissue  is  retarded  in  the 
body. 

Regarding  the  statement  of  some  authorities  that  alcohol  does 
not  undergo  any  change  in  the  body,  but  is  excreted  unchanged, 
Binz  asserts1  that  alcohol  appears  in  the  urine  only  when 
exceptionally  large  quantities  have  been  taken,  and  then  in  very 
small  proportion.  It  is  not  excreted  by  the  lungs,  the  peculiar 
odor  of  the  breath  being  due  not  to  the  alcohol,  but  to  the 
volatile  aromatic  ether,  which  is  oxidized  with  greater  difficulty, 
and  so  escapes  unchanged. 

While  alcohol  produces  subjectively  an  agreeable  sensation 
of  warmth  in  the  stomach  and  on  the  surface  of  the  body,  the 
bodily  temperature  is  not  raised.  The  subjective  sensation  is 
due  to  the  dilatation  of  the  blood-vessels  and  the  sudden  hyper- 
eemia  of  those  parts. 

During  fevers  and  other  exhausting  diseases,  alcohol  is 
invaluable  to  prevent  waste  of  tissue  and  sustain  the  strength. 
It  does  not  act  merely  as  a  stimulant  to  the  circulation  and 
nervous  system,  but,  as  above  pointed  out,  saves  the  more  stable 
compounds  by  furnishing  a  readily  oxidizable  respiratory  food. 

When  taken  in  small  doses  by  healthy  persons,  alcohol 
diminishes  the  temperature  by  increasing  heat-radiation.  When 
large  quantities  are  taken,  the  bodily  temperature  is  reduced  by 
diminishing  heat  production,  as  well  as  by  increased  radiation. 
This  is  shown  in  the  condition  known  as  dead-drunkenness,  in 
which  the  temperature  is  sometimes  depressed  as  much  as  20°  F. 
below  the  normal.  Cases  in  which  the  temperature  sank  to  75°, 
78.8°,  and  83°  F.  have  been  reported,  with  recovery  in  all  cases. 

1  Bealencyclopaedie  d.  ges.  Heilk.,  Bd.  I,  p.  183. 


BEVERAGES  CONTAINING  ALCOHOL.  119 

The  constant  use  of  alcohol  produces  in  all  the  organs  an 
excess  of  connective  tissue,  followed  by  fatty  degeneration  and 
the  condition  known  as  cirrhosis.  The  organs  most  frequently 
affected  are  the  stomach,  liver,  and  kidneys.  Serious  pathological 
alterations  also  occur  in  the  circulatory,  respiratory,  and  nervous 
systems. 

Alcohol  is  not  necessary  to  persons  in  good  health.  Prob- 
ably most  persons,  regardless  of.  their  state  of  health,  do  better 
without  it.  Its  habitual  use  in  the  form  of  strong  liquors  is 
to  be  unreservedly  condemned.  The  lighter  wines  and  malt 
liquors,  if  obtained  pure,  may  be  consumed  in  moderate  quanti- 
ties without  ill  effects.  Even  in  these  forms,  however,  the  use 
of  alcohol  should  be  discouraged  or,  perhaps,  prohibited  in  the 
young. 

Neither  in  hot  nor  in  cold  climates  is  alcohol  necessary  to 
the  preservation  of  health,  and  its  moderate  use  even  produces 
more  injury  than  benefit.  The  Polar  voyager  and  the  East 
India  merchant  are  alike  better  off  without  alcohol  than  with  it. 

It  has  long  been  a  prevalent  belief  that  the  use  of  alcohol 
enables  persons  to  withstand  fatigue  better  than  where  no  alcohol 
is  used.  A  large  amount  of  concurrent  testimony  absolutely 
negatives  this  belief.1 

The  predisposition  to  many  diseases  is  greatly  increased  by 
the  habitual  use  of  alcohol.  Sun-stroke,  the  acute  infectious 
diseases,  and  many  local  organic  affections  attack,  by  preference, 
the  intemperate.  A  recent  collective  investigation  by  the  British 
Medical  Association  brought  out  the  fact  that  croupous  pneu- 
monia is  vastly  more  fatal  among  the  intemperate  than  among 
those  who  abstained  from  the  use  of  alcoholic  liquors. 

A  further  investigation  by  Baer  has  shown  that  the  average 
expectation  of  life  among  users  and  dealers  in  alcoholic  liquors 
is  very  much  shortened.  The  following  table  gives  a  compara- 
tive view  of  the  expectation  of  life  in  those  who  abstained  from 
and  those  who  used  alcohol: — 

1  See  Parkes'  Hygiene,  6th  ed.,  vol.  i,  pp.  315-327. 


120 


TEXT-BOOK   OF    HYGIENE. 


TABLE  XIV. 

EXPECTATION   OF   LIFE. 


Age. 

Abstainers. 

Alcohol  Users. 

At  25     

32.08  years. 

26.23  years. 

"35    

25.92      " 

20.01       " 

"45     

19.92      " 

15.19       " 

"55     

14.45       " 

11.16       " 

"65     

9.62       " 

8.04       " 

Table  XV  shows  the  influence  of  alcohol  upon  the  mortality 
from  various  diseases : — 

TABLE  XV. 


General  Male  Popu- 
lation (per  cent.). 

Alcohol  Venders 
(per  cent.). 

Brain  disease      

11.77 

14.43 

Tuberculosis  

30.36 

36.57 

Pneumonia  and  pleuritis      .... 
Heart  disease      

9.63 
1.46 

11.44 
3.29 

Kidnev  disease  . 

1.40 

2.11 

*/ 
Suicide  

2.99 

4.02 

Cancer  •... 

2.49 

3.70 

Old  age      .               

22.49 

7.05 

Alcohol  as  a  beverage  is  consumed  in  the  various  forms  of 
spirits,  wines,  and  fermented  liquors.  The  varieties  of  spirits 
most  frequently  used  are  brandy,  whisky,  rum,  and  gin.  They 
are  all  procured  by  distillation. 

Brandy  is  distilled  from  fermented  grape-juice,  and  has  a 
characteristic  aromatic  flavor.  When  pure  and  mellowed  with 
age  it  is  the  most  grateful  to  the  palate  of  all  distilled  spirits. 

Whisky  is  distilled  from  barley,  rye,  oats,  corn,  or  potatoes. 
Each  of  these  has  a  peculiar  flavor,  depending  upon  the  par- 
ticular volatile  ether  formed  during  the  distillation.  Rye-,  barley-, 
and  corn-  whiskies  are  almost  exclusively  used  in  this  country. 


BEVERAGES  CONTAINING  ALCOHOL.  121 

Rum  is  distilled  from  molasses,  and  is  a  favorite  ingredient 
in  hot  punches.  It  is  often  used  with  milk,  eggs,  and  sugar,  in 
the  preparation  of  eggnog,  a  highly-nutritious,  stimulating  drink, 
which  is  often  prescribed  with  great  benefit  in  acute  and  chronic 
wasting  diseases. 

Gin  is  an  ardent  distilled  spirit,  flavored  with  oil  of  juniper. 
It  has  a  widely-spread  popular  reputation  as  a  cure  for  kidney 
diseases,  but  is  probably  oftener  responsible  for  the  production 
of  these  diseases  than  for  their  cure. 

All  of  the  above-mentioned  liquors  contain  from  40  to  60 
per  cent,  of  alcohol,  and  should  always  be  diluted  before  being 
taken  into  the  stomach,  in  order  to  prevent  the  local  irritant 
effects  of  the  alcohol  upon  the  gastric  mucous  membrane. 

Wine  is  the  product  of  the  alcoholic  fermentation  of  the 
saccharine  constituents  of  fruits.  Wine  is  usually  derived  from 
the  grape,  though  other  fruits  may  also  furnish  it.  The  stronger 
wines  (sherry,  port,  madeira)  contain  from  16  to  25  per  cent, 
of  alcohol.  The  lighter  wines  (hock,  red  and  white  Bordeaux 
and  Burgundy  wines,  champagnes)  contain  from  6  to  15  per 
cent,  of  alcohol.  Some  also  contain  considerable  free  carbonic 
acid  (sparkling  wines),  of  which  the  champagnes  are  types.  The 
red  and  white  Bordeaux  and  Rhine  wines  are  probably  the 
least  objectionable  of  these  beverages  for  habitual  use.  They 
contain  sufficient  alcohol  to  be  lightly  stimulant,  have  a  pleasant 
acid  flavor,  and  are  least  likely  to  produce  the  bad  effects  which 
usually  follow  in  the  wake  of  the  habitual  use  of  the  stronger 
wines  or  ardent  spirits. 

Preference  should  be  given  to  the  wines  of  domestic  manu- 
facture, on  account  of  the  great  probability  of  adulteration  of  the 
favorite  brands  of  foreign  wines.  Many  of 'the  California,  Vir- 
ginia, New  York,  and  Ohio  wines  compare  very  favorably  in 
flavor  with  those  imported  from  abroad.  The  more  reasonable 
cost  of  these  domestic  wines  is  also  a  point  in  their  favor. 

Cider  is  the  fermented  juice  of  apples.  It  frequently  pro- 
duces unpleasant  gastric  and  intestinal  disturbances  when  drunk, 


122  TEXT-BOOK   OF   HYGIENE. 

on  account  of  the  large  quantity  of  malic  acid  contained  in  it. 
Although  it  is  usually  ranked  as  a  "  temperance  drink,"  it  is 
quite  capable  of  causing  intoxication  when  consumed  in  large 
quantities. 

Beer  is  the  fermented  extract  of  barley,  mixed  with  a 
decoction  of  hops  and  boiled.  It  should  be  prepared  only  of 
malt,  hops,  yeast,  and  water,  and  should  contain  from  3  to 
4  per  cent,  of  alcohol,  5  to  6  per  cent,  of  extract  of  malt 
and  hops,  2  to  4  per  cent,  of  lactic  and  acetic  acids,  and  from 
^  to  ^  per  cent,  of  carbonic  acid.  This  ideal  is,  how- 
ever, rarely  attained  in  the  article  sold  by  the  liquor  dealer. 
Numerous  adulterations  are  practiced  on  the  unsuspecting  con- 
sumer. The  hops  are  frequently  substituted  by  aloes,  calamus, 
and  ginger,  or  by  the  more  deleterious  picric  acid  or  picrotoxin. 
The  rich  brown  color,  sweetness,  body,  and  creamy  foam  are 
produced  by  caramel  and  glycerin.  The  more  expensive  barley- 
malt  is  substituted  by  starch  and  rice,  or  grape-sugar  and 
molasses. 

Ale,  porter,  and  brown-stout  are  merely  varieties  of  beer — 
some  containing  more  sugar,  others  more  extractive  matter. 

Beer  and  its  correlatives  have  considerable  dietetic  value, 
owing  not  merely  to  the  alcohol  they  contain,  but  largely  to  the 
sugar  and  acids  entering  into  their  composition.  When  used  to 
excess  they  often  cause  a  considerable  accumulation  of  fat. 

Kumys  is  the  national  beverage  of  the  nomadic  tribes  of 
Tartary.  It  consists  of  the  milk  of  mares  which  has  undergone 
fermentation,  partly  lactic  and  partly  alcoholic  in  character. 
Recently  it  has  been  introduced  into  Europe  and  also  into  this 
country,  where  it  is  made  of  cows'  milk.  It  is  a  palatable, 
nutritious  stimulant,  and  is  often  very  useful  as  a  dietetic  article 
in  disease. 

Kefyr  is  a  product  of  the  fermentation  of  milk  which  bears 
some  resemblance  to  kumys.  The  following  table  (Table  XVI) 
gives  a  comparative  view  of  the  composition  of  true  kumys,  the 
same  prepared  from  cows'  milk,  and  kefyr : — 


ALKALOIDAL    BEVERAGES. 


123 


TABLE  XVI. 


True  Kumys 
(percent.). 

Cows'  Milk  Kumys 
(percent.). 

Kefyr 
(per  ce'nt.). 

Proteids     .     

2.20 

2  35 

3  12 

Fats       

2.12 

2.0T 

1  95 

Su^ar 

1.53 

1.81 

1  62 

Lactic  acid     

0.90 

0  40 

0  83 

Alcohol      

1.72 

1.90 

2  10 

C00 

0.85 

0.80 

0  92 

THE   ALKALOIDAL   BEVERAGES. 

The  virtues  of  the  alkaloidal  beverages  depend  upon  certain 
alkaloids  which  differ  very  little  in  their  chemical  composition 
or  physiological  effects,  and  upon  certain  volatile  aromatic  con- 
stituents of  the  various  articles  used.  The  principal  articles 
employed  in  the  preparation  of  these  beverages  are  coffee,  tea, 
chocolate,  mate,  and  coca.  It  is  estimated  that  500,000,000 
people  drink  coffee,  100,000,000  tea,  50,000,000  chocolate, 
15,000,000  mate  or  Paraguay  tea,  and  10,000,000  coca.  All 
of  these  are  active  nervous  stimulants  and  retarders  of  tissue- 
waste.  They  are  all  liable  to  produce  serious  functional  dis- 
turbances of  the  nervous,  digestive,  and  circulatory  systems  if 
used  to  excess.  Anaemia,  digestive  derangements,  constipation, 
pale,  sallow  complexion,  loss  of  appetite,  disturbed  sleep,  nervous 
headaches  and  neuralgias  are  the  most  marked  of  these  effects. 

On  the  other  hand,  when  taken  in  moderate  quantity,  the 
alkaloidal  beverages  enable  the  consumer  to  withstand  cold, 
fatigue,  and  hunger ;  they  promptly  remove  the  sensation  of 
hunger,  and  diffuse  a  glow  of  exhilaration  throughout  the  body. 

Coffee. — Coffee  is  the  ripe  fruit  (seed)  of  the  Cnffea  Arabica, 
a  native  of  Arabia  and  Eastern  Africa,  but  now  cultivated  in 
other  tropical  regions  of  the  world.  The  fruit  consists  of  two 
flat-convex  beans,  the  flat  surfaces  of  which  are  apposed  to  each 
other.  These  are  enclosed  in  a  fibrous  envelope  which  is  some- 
times used  as  a  cheap  substitute  for  the  coffee-bean. 

The  beverage,   coffee,  is  an  infusion  of  the  roasted  and 


124  TEXT-BOOK    OF    HYGIENE. 

ground  bean  in  hot  water.  Its  virtues  depend  upon  the  alkaloid, 
caffein,  and  an  aromatic  oil.  The  latter,  being  volatile,  is  driven 
off  by  long-continued  heat.  Hence  boiled  coffee  lacks  the 
grateful  aroma  of  that  which  is  made  by  simply  infusing  the 
ground  bean  in  hot  water. 

The  great  demand  for  coffee  and  its  comparatively  high 
price  have  caused  it  to  be  extensively  adulterated  and  substituted 
by  other  natural  and  artificial  products.  Artificial  coffee-beans 
have  been  made  of  clay,  dough,  or  extract  of  chicory,  colored 
to  imitate  the  natural  bean.  The -fraud  is  easily  detected  by 
placing  the  beans  in  water,  when  the  artificial  product  soon  falls 
to  pieces,  while  the  natural  beans  undergo  no  change  of  shape 
or  consistence. 

Ground  coffee  as  found  in  the  stores  is  usually  adulterated. 
The  materials  used  for  sophistication  are :  The  grounds  of  coffee 
previously  used,  the  roasted  root  of  chicory,  acorns,  rye  or  barley, 
carrots,  sunflower-seeds,  caramel,  and  a  number  of  articles  of 
similar  value,  generally  harmless. 

Tea. — The  plants  which  furnish  the  tea-leaves  are  natives 
of  China,  Indo-China,  and  Japan.  The  tea-leaves  contain  a 
crystalline  alkaloid,  thein,  identical  in  composition  and  proper- 
ties with  caffein.  The  various  sorts  of  tea  found  in  the  market 
(green  and  black  teas,  etc.)  differ  only  in  the  relative  proportion 
of  tannin  and  thein  contained  in  each.  The  aromatic  principle 
also  varies  somewhat  in  the  different  sorts. 

Tea  is  adulterated  to  quite  as  great  an  extent  as  coffee,  the 
leaves  of  various  plants  bearing  more  or  less  resemblance  to  tea- 
leaves  being  added  to  the  latter.  Much  of  the  tea  found  in  the 
market  is  colored  artificially  with  Prussian  blue  and  iron  oxide. 
These  additions  are  harmless,  as  they  are  not  soluble  in  water. 

Cliocolate. — Cocoa,  from  which  chocolate  is  derived,  is 
widely  different  in  composition  from  tea  and  coffee.  In  addi- 
tion to  its  active  principle,  theobromin,  which  is  identical  with 
caffein  and  thein,  it  contains  nearly  50  per  cent,  of  fat,  which 
renders  it  an  article  of  high  nutritive  value. 


TOBACCO.  125 

Mate,  or  Paraguay  tea,  guarana,  and  coca  are  used  to  a 
considerable  extent  in  some  parts  of  South  America  as  substi- 
tutes for  coffee  and  tea.  Their  composition  is  not  well  known, 
but  their  effects  are  believed  to  depend  upon  alkaloidal  princi- 
ples similar  to  caffein  and  thein. 

TOBACCO. 

Closely  connected  with  the  subjects  treated  in  this  chapter 
are  the  effects  of  the  constant  use  of  tobacco  upon  the  human 
system  The  depressing  effects  of  tobacco,  due  principally  to 
the  nicotine  upon  the  nervous  and  digestive  systems,  have  long 
been  recognized.  Recently,  however,  it  has  been  found  that 
very  serious  symptoms  are  produced  upon  the  sense  of  vision  by 
the  constant  or  excessive  use  of  tobacco.  A  special  form  of 
amaurosis,  termed  tobacco  amaurosis,  has  been  frequently  noticed 
since  attention  was  first  called  to  it  by  Mackenzie. 

[The  following  additional  works  are  recommended  to  the 
student : — 

Thos.  K.  Chambers,  on  Diet  in  Health  and  Disease. — Edward  Smith, 
on  Foods. — Forster,  Ernahrung,  in  Pettenkofer  u.  Ziemssen's  Handbuch 
der  Hygiene. — Munk  und  Uffelmann,  Die  Ernahrung  des  Gesunden  und 
K  ran  ken  Menschen. — I.  Barney  Yeo,  Food  in  Health  and  Disease. — 
Kenwood,  The  Hygienic  Laboratory,  Part  V.] 


QUESTIONS   TO    CHAPTER   III. 

FOOD. 

What  is  a  food  ?  What  reasons  have  we  for  stating  that  the  proxi- 
mate food  principles  must  be  combined  in  definite  proportions  to  main- 
tain a  normal  degree  of  health?  What  are  the  alimentary  principles 
necessary  to  man's  existence  ?  Why  do  we  need  water  ?  What  are  the 
functions  of  the  salts  in  our  foods  ?  Is  existence  possible  without  a 
sufficient  supply  of  nitrogenous  food  ?  What  is  the  relation  of  starch 
to  fat  as  oxidizable  food  ? 

Are  the  proteid  tissues  of  the  body  derived  solely  from  the  nitroge- 
nous foods?  What  are  the  sources  of  the  body-fat?  What  tissues  are 
mostly  consumed  during  work? 

What  is  the  relation  between  the  proximate  food  principles,  and 
what  amount  of  each  is  necessary  in  the  standard  daily  diet  of  a  man  at 
rest?  At  moderate  labor?  At  hard  work?  About  what  is  the  relation  of 
nitrogenous  to  non-nitrogenous  food  ?  Of  nitrogen  to  carbon  ?  Is  a 
standard  diet  necessarily  an  expensive  one?  How  may  it  be  selected  ? 

Why  is  a  variety  in  the  kind  of  food  necessary  ?  Why  may  not  a 
man  live  on  nitrogenous  foods,  like  meat,  alone?  Why  not  on  non- 
nitrogenous  food,  like  potatoes  ? 

Has  climate  much  influence  upon  the  amount  of  food  needed  ?  Has 
it  upon  the  kind  of  food  ?  What  kind  of  food  is  especially  beneficial  for 
a  laboring  man  in  cold  weather?  Where  do  we  find  the  proteid  prin- 
ciples of  food  ?  Where  the  fatty  ?  Where  the  carbohydrates  ?  The 
salts  ?  Why  should  only  a  moderate  amount  of  food  be  taken,  and  why 
should  it  be  properly  prepared?  What  are  some  of  the  factors  that 
increase  the  consumption  of  carbonaceous  foods  ?  Does  increased 
physical  labor  increase  the  demand  for  nitrogenous  foods?  Which 
requires  the  most  carbonaceous  food,  physical  or  mental  labor?  What 
maladies  especially  require  fat-producing  foods  ?  Has  the  food  that  a 
man  eats  anything  to  do  with  his  moral  character  ? 

How  may  we  classify  food?  Name  some  of  animal  origin.  From 
the  vegetable  kingdom.  What  is  the  function  of  condiments?  Of 
stimulants  ? 

Why  is  milk  so  nearly  a  perfect  food  ?  What  is  the  average  compo- 
sition of  cows'  milk?  What  is  the  difference  between  human  milk  and 
cows'  milk  ?  What  other  substitutes  are  sometimes  used  for  human 
milk? 

(126) 


QUESTIONS   TO   CHAPTER   III.  127 

What  is  cream?  What  changes  take  place  in  milk  upon  standing 
for  some  time?  To  what  are  these  changes  due?  What  is  made  from 
the  curd?  Has  whey,  or  butter-milk,  any  food  value? 

What  should  be  the  specific  gravity  of  milk?  How  is  it  deter- 
mined? What  may  lower  the  specific  gravity?  What  may  raise  it? 
Has  "  skim-milk  "  a  food  value  ?  What  is  the  objection  to  its  sale  ? 

How  is  milk  frequently  adulterated?  How  may  this  be  detected? 
Why  is  the  addition  of  water  dangerous?  How  else  might  the  milk 
become  infected  ? 

May  infectious  diseases  be  transmitted  from  the  cow  to  man  through 
the  milk?  How  may  this  danger  of  infection  be  avoided?  What 
diseases  are  especially  likely  to  be  thus  conveyed  by  the  milk  ?  Give  an 
account  of  the  l>  Hendon  cow  disease."  May  the  milk  of  animals  suffer- 
ing from  certain  febrile  diseases  be  dangerous  to  health  ?  Is  the  milk 
of  cows  fed  on  distillery  or  brewery  refuse  necessarily  unwholesome  ? 

How  may  the  quality  of  a  milk  be  determined  ?  What  is  a  lacto- 
scope?  What  is  a  creamometer  ?  What  should  be  the  minimum  per- 
centage of  cream  ?  How  may  the  rapid  fermentation  of  milk  be  pre- 
vented? What  is  tyrotoxicon,  and  to  what  is  it  due? 

What  is  butter  ?  What  is  its  food  value,  and  why  ?  What  change 
does  it  undergo  in  becoming  "rancid"?  How  is  it  often  sophisticated? 
What  is  oleo-marg.irine  or  butterine?  How  is  it  made?  Is  it  unwhole- 
some, and  is  there  any  objection  to  its  use  if  sold  under  its  proper  name? 
Upon  what  does  the  value  of  cheese  depend  ?  Is  it  nutritious  ?  Why 
cannot  large  quantities  be  eaten  at  a  time  ? 

Which  are  the  richest  kinds  of  cheese?  Is  cheese  often  adulter- 
ated ?  How  may  cheese  be  made  more  digestible  ?  What  dangerous 
change  may  it  undergo,  and  to  what  is  this  due  ? 

Why  is  meat  such  an  important  article  of  food?  What  is  the  per- 
centage of  proteids  and  fats  in  the  meats  commonly  used  ?  Upon  what 
does  the  variation  between  these  two  principles  depend  ?  Should  meat 
be  cooked  and  eaten  immediately  after  death  ?  Should  it  be  kept  too 
long  after  death  before  being  used  ?  Why  should  meat  be  always 
cooked  ?  What  are  the  common  methods  of  cooking  ?  Are  beef-extracts 
really  nutritious  ?  Are  partially  or  wholly  predigested  preparations  of 
meat  nutritious?  What  is  the  objection  to  their  continued  use? 

What  conditions  may  render  meat  unfit  for  food  ?  How  may  the 
various  parasites  in  meat  be  destroyed?  What  animals  are  apt  to  be 
infested  with  trichinae  ?  In  what  two  forms  are  the  trichinae  found  in  ani- 
mals ?  How  do  they  gain  access  to  the  muscles  ?  May  salted  or  smoked 


128  QUESTIONS   TO   CHAPTER   III. 

meat  contain  living  trichinae  ?  Of  what  parasite  is  the  Cysticercus  cellu- 
losa  a  transition  form  ? 

What  may  be  the  result  of  using  partially-decomposed  meat  or  fish? 
To  what  are  the  serious  results  due?  How  are  the  ptomaines  produced? 
What  is  their  probable  chemical  nature?  What  peculiar  idiosyncrasy 
have  some  people  regarding  shell-fish  ?  What  infectious  diseases  may  be 
transmitted  to  human  beings  by  the  consumption  of  infected  meat  ? 
When  and  by  whom  should  meat  be  inspected  ? 

Why  are  eggs  so  highly  valued  for  food  ?  In  which  form  are  eggs 
most  digestible  ?  Why  do  eggs  undergo  putrefaction  so  readily  ? 

What  cereals  are  used  in  making  bread  ?  What  part  of  the  grain 
contains  the  greater  proportion  of  proteids?  Is  all  the  gluten- to  be 
found  in  the  bran?  Which  flours  are  most  nutritious  and  which  most 
digestible?  What  are  some  of  the  characteristics  of  good  bread?  To 
what  is  the  porosity  due,  and  how  is  it  produced?  How  may  the  loss 
of  starch  by  fermentation  be  avoided  ?  How  is  flour  often  adulterated  ? 
Why  is  alum  added  to  flour?  What  disease  of  grain  may  be  harmful  to 
the  health  of  the  users  ? 

What  is  the  chief  constituent  of  potatoes  and  rice  ?  In  what  prin- 
ciple are  the  leguminous  foods  especially  rich  ?  Wherein  is  the  chief 
value  of  green  vegetables?  Why  are  fruits  and  nuts  valuabe  as  articles 
of  diet  ?  What  rule  should  be  observed  regarding  the  use  of  condiments  ? 

Why  should  physicians  know  considerable  about  cooking?  What 
are  the  various  methods  of  cooking?  What  is  the  effect  of  boiling 
upon  meats?  What  points  are  to  be  observed  in  the  boiling  of  meat? 
In  the  making  of  soups,  etc.  ?  What  valuable  principle  is  lost  if  vege- 
tables are  boiled  too  long?  What  is  the  secret  in  making  good  coffee? 
What  is  frying?  Ho\v  should  it  be  done?  How  should  meats  be  roasted ? 
Why  are  broiling  and  baking  generally  satisfactory  processes? 

Into  what  two  classes  may  alimentary  beverages  be  divided  ?  For 
what  are  those  of  the  second  class  used  ?  What  is  the  pl^siological  effect 
and  action  of  alcohol  upon  the  nerve-centres  ?  Upon  the  circulation  ?  Is 
it  changed  before  absorption  ?  Does  it  nourish  the  body  ?  Does  it  supply 
heat  ?  Does  it  raise  the  body-temperature  ?  What  effect  has  it  on  heat- 
production  and  heat-radiation?  On  tissue  waste?  How  is  it  excreted? 
What  effect  have  small  amounts  of  alcohol  upon  digestion  ?  What  patho- 
logical changes  are  brought  about  by  the  constant  use  of  alcohol  ?  Is  it 
necessary  or  beneficial  to  persons  in  good  health?  Why  is  it  so  valuable 
in  fevers  and  wasting  diseases?  Does  it  enable  persons  to  withstand 
fatigue  ?  To  what  diseases  is  the  predisposition  increased  by  the  habitual 
use  of  alcohol?  What  effect  has  it  upon  the  expectation  of  life  and 


QUESTIONS   TO   CHAPTER   III.  129 

upon  the  mortality  from  various  diseases  ?  If  used  habitually,  what  forms 
should  be  chosen  ?  What  is  the  difference  between  spirits,  wines,  and 
malt  liquors?  What  is  brandy?  From  what  is  whisky  made?  How 
much  alcohol  do  the  various  spirits  contain,  and  what  rule  should  be 
observed  regarding  their  use  ?  What  percentage  of  alcohol  do  the  various 
wines  contain  ?  Which  are  the  least  objectionable  for  habitual  use  ? 
What  can  be  said  regarding  the  domestic  wines?  To  what  disturbances 
may  cider  give  rise,  and  why  ?  From  what  articles  alone  should  beer  be 
made  ?  How  much  alcohol  should  it  contain  ?  With  what  substances  is  it 
often  sophisticated  ?  Have  beer,  ale,  etc.,  a  dietetic  value,  and  why  ?  What 
may  be  the  result  when  beer  is  used  to  excess?  What  is  kumyss  and 
kefyr  ?  Why  are  they  valuable  in  sickness  ?  How  much  alcohol  does  each 
contain?  Upon  what  do  the  virtues  of  the  alkaloidal  beverage  depend? 
What  are  the  principal  articles  employed  in  their  preparation  ?  What 
is  the  physiological  action  of  all  these  substances  ?  What  are  some  of 
the  effects  if  they  are  used  to  excess?  What  is  their  effect  when  used  in 
moderation  ?  May  they  be  used  as  substitutes  for  alcohol  ? 

What  is  coffee,  and  what  alkaloid  does  it  contain  ?  What  else  does 
it  contain  that  gives  value  to  the  beverage?  How  is  coffee  adulterated, 
and  how  may  fraud  be  detected  ?  What  is  tea,  and  what  alkaloid  does 
it  contain  ?  How  may  it  be  adulterated  ?  Why  is  cocoa  of  greater  food 
value  than  tea  or  coffee  ?  What  is  its  active  principle,  and  what  is  its 
relation  to  thein  and  caffeiu  ?  What  is  the  difference  between  cocoa  and 
chocolate  ?  What  are  the  effects  of  tobacco  upon  the  human  system,  and 
to  what  are  they  due  ? 


CHAPTER  IV. 

SOIL. 

HIPPOCRATES  treated  at  length,  in  one  of  his  works,  of  the 
sanitary  influences  of  the  soil.  Others  of  the  older  writers, 
especially  Herodotus  and  Galen,  called  attention  to  the  same 
subject,  and  Vitruvius,  the  celebrated  Roman  architect,  who 
flourished  about  the  beginning  of  the  Christian  era,  taught  that 
a  point  of  first  importance  in  building  a  dwelling  was  to  select  a 
site  upon  a  healthy  soil. 

From  this  time  until  the  beginning  of  the  eighteenth  cen- 
tury, very  little  of  value  is  found  in  medical  literature  bearing 
upon  this  subject.  In  1717,  however,  Lancisi  published  his 
great  work  on  the  causes  of  malarial  fevers,  in  which  he  laid 
the  foundation  for  the  modern  theory  of  malaria,  and  pointed 
out  the  relations  existing  between  marshes  and  low-lying  lands 
and  those  diseases  by  common  consent  called  malarial.  Other 
authors  of  the  eighteenth  and  the  early  part  of  the  nineteenth 
centuries  refer  to  the  connection  between  the  soil  and  disease, 
but  exact  investigations  have  only  been  made  within  the  last 
thirty  years. 

When  it  is  considered  that  the  air  that  human  beings 
breathe,  and  much  of  the  water  they  drink,  are  influenced  in 
their  composition  by  the  matters  in  the  soil,  the  great  importance 
of  possessing  a  thorough  knowledge  of  the  physical  and  chemical 
conditions  of  the  soil  becomes  evident  to  every  one. 

PHYSICAL   AND   CHEMICAL   CHARACTERS   OF   THE    SOIL. 

In  the  hygienic,  as  in  the  geological  sense,  rock,  sand,  clay, 
and  gravel  are  included  in  the  consideration  of  soils. 

The  soil,  as  it  is  presented  to  us  at  the  surface  of  the  earth, 

(131) 


132  TEXT-BOOK   OF    HYGIENE. 

is  the  result  of  long  ages  of  disintegration  of  the  primitive 
rocks  by  the  action  of  the  elements,  of  the  decomposition  of 
organic  remains,  and,  possibly,  of  accretions  of  cosmical  dust. 
The  principal  factor,  however,  is  the  action  of  water-upon  rock, 
in  leveling  the  projections  of  the  earth's  surface  produced  by 
volcanic  action. 

Soils  vary  considerably  in  physical  and  chemical  constitu- 
tion. A  soil  may,  for  example,  consist  exclusively  of  sand,  of 
clay,  or  of  disintegrated  calcareous  matter.  Other  soils  may 
consist  of  a  mixture  of  two  or  more  of  these,  together  with 
vegetable  matter  undergoing  slow  oxidation.  In  forests,  a  layer 
of  this  slowly-decomposing  vegetable  matter  of  varying  thick- 
ness is  found,  covering  the  earthy  substratum.  This  organic 
layer  is  called  humus,  and  when  turned  under  by  plough  or 
spade,  and  mixed  with  the  sand  or  clay  base,  it  constitutes  the 
ordinary  agricultural  soil. 

THE   ATMOSPHERE   OF   THE    SOIL,   OR   GROUND-AIR. 

The  interstices  of  the  soil  are  occupied  by  air  or  water,  or 
by  both  together.  The  soil's  atmosphere  is  continuous  with, 
and  resembles  in  physical  and  chemical  properties,  that  which 
envelops  the  earth.  Its  proportion  to  the  mass  of  the  soil 
depends  upon  the  degree  of  porosity  of  the  soil,  and  upon  the 
amount  of  moisture  present.  In  a  very  porous  soil,  such  as,  for 
example,  a  coarse  sand,  gravelly  loam,  or  coarse-grained  sand- 
stone, the  amount  of  air  is  much  greater  than  in  a  clayey  soil, 
granite,  or  marble.  So,  likewise,  when  the  soil  contains  a  large 
proportion  of  water,  the  air  is  to  this  extent  excluded.  The 
porosity  of  the  various  soils,  as  evidenced  by  the  amount  of  air 
contained  in  them,  is  much  greater  than  would,  at  first  thought, 
be  supposed.  Thus  it  has  been  found  that  porous  sandstone 
may  contain  as  much  as  one-third  of  its  bulk  of  air,  while  the 
proportion  of  air  contained  in  sand,  gravel,  or  loose  soil  may 
amount  to  from  30  to  50  per  cent. 

The  ground-air  is  simply  the  atmospheric  air  which  has 


THE   ATMOSPHERE   OF   THE    SOIL,    OR   GROUND-AIR.  133 

penetrated  into  the  interstices  of  the  soil  and  taken  part  in  the 
various  chemical  decompositions  going  on  there.  In  consequence 
of  these  chemical. changes  the  relative  proportions  of  the  oxygen 
and  carbonic  acid  in  the  air  are  changed — oxygen  disappearing 
and  giving  place  to  carbon  dioxide.  It  is  well  known  that 
during  the  decay  of  vegetable  matter  in  the  air  carbon  dioxide 
is  formed;  one  constituent  of  this  compound,  the  carbon,  being 
derived  from  the  vegetable  matter,  while  the  oxygen  is  taken 
from  the  air.  Hence,  if  this  action  takes  place  where  their  is 
not  a  very  free  circulation  of  air,  as  in  the  soil,  the  air  there 
present  soon  loses  its  normal  proportion  of  oxygen,  which  enters 
into  combination  with  the  carbon  of  the  vegetable  matter  to 
form  carbon  dioxide. 

Thirty  years  ago,  MM.  Boussingault  and  Levy,  two  dis- 
tinguished French  chemists,  examined  the  air  contained  in 
ordinary  agricultural  soil,  and  found  that  the  oxygen  was 
diminished  to  about  one-half  of  the  proportion  normally  present 
in  atmospheric  air,  while  the  carbon  dioxide  was  enormously 
increased.  The  exact  results  obtained  by  Boussingault  and 
Levy  were  as  follow: — 

In  100  volumes  of  ground-air  there  were  10.35  volumes 
of  oxygen,  79.91  volumes  of  nitrogen,  9.74  volumes  of  carbon 
dioxide.  In  atmospheric  air,  on  the  other  hand,  there  are  in 
100  volumes  20.9  volumes  of  oxygen,  79.1  volumes  of  nitrogen, 
0.04  volume,  or  about  -£-%  of  1  per  cent,  of  carbon  dioxide. 

In  spite  of  the  striking  results  obtained  by  these  two 
chemists,  very  little  attention  was  paid  to  them  by  sanitarians,  as 
very  few  seemed  to  have  any  clear  notion  of  the  relations  exist- 
ing between  the  motions  of  the  air  above-ground  and  that  under- 
ground. 

In  1871,  however,  Professor  von  Pettenkofer,  of  Munich, 
published  the  results  of  his  own  examinations  into  the  constitu- 
tion and  physical  conditions  of  the  ground-air,  and  the  relations 
of  the  latter  to  the  propagation  of  epidemic  diseases.  These  re- 
searches, which  created  a  wide-spread  interest  in  the  subject, 


134  TEXT-BOOK   OF    HYGIENE. 

were  extended  by  other  observers  in  all  parts  of  the  world. 
These  observers,  prominent  among  whom  were  Professors  Fleck, 
Fodor,  and  Soyka,  in  Germany ;  Drs.  Lewis  and  Cunningham, 
in  India ;  Prof.  William  Ripley  Nichols,  in  Boston ;  and  Sur- 
geons J.  H.  Kidder  and  S.  H.  Griffith,  of  the  U.  S.  Navy,  in 
Washington,  demonstrated  that  the  increase  of  carbon  dioxide 
in  the  ground-air  is  due  to  increased  vegetable  decomposition 
and  to  lessened  permeability  of  the  soil.  A  permeable,  that  is 
to  say,  a  sandy  or  gravelly  soil  is  likely  to  contain  less  carbon 
dioxide  in  its  atmosphere  than  a  dense,  less  permeable  clay, 
although  the  amount  of  decomposition  going  on  and  the  pro- 
duction of  carbon  dioxide  in  the  former  may  considerably  ex- 
ceed the  latter.  In  the  loose,  sandy  soil  the  circulation  of  the 
air  is  less  obstructed,  and  the  carbon  dioxide  may  easily  escape 
and  be  diffused  in  the  superincumbent  air,  while  the  close-pored 
clay  imprisons  the  carbon  dioxide  and  prevents  or  retards  its 
escape  into  the  air  above. 

The  disappearance  of  oxygen  from  the  ground-atmosphere 
is  coincident  with  the  production  of  an  equivalent  amount  of 
carbon  dioxide.  It  appears  from  this  that  in  the  soil  an  OX' 
idation  of  carbonaceous  substances  takes  place,  the  product  of 
which  is  found  in  the  excess  of  carbon  dioxide  in  the  ground-air. 

Professor  Nichols  has  found  the  proportion  of  carbon  di- 
oxide in  the  air  taken  from  a  depth  of  3  metres  below  the 
surface  in  the  "made-land"  of  Boston  to  amount  to  21.21  per 
thousand,  the  observation  having  been  made  in  August.  In 
December,  at  a  depth  of  2  metres,  the  proportion  was  3.23  per 
thousand.  Fodor,  in  Buda-Pesth,  found  the  proportion  of  carbon 
dioxide  to  be  107.5  per  thousand  (over  10  per  cent.),  the  air 
having  been  taken  from  a  depth  of  3  metres. 

The  ground-air  also  teems  with  micro-organisms  of  various 
kinds,  these  being  occasionally  pathogenic.  While  in  the  great 
majority  of  instances  the  micro-organisms  found  are  ordinary 
mold  or  fermentation  fungi  and  bacteria  of  decay  and  putrefac- 
tion, disease-producing  bacilli  have  also  been  observed  in  a 


THE   ATMOSPHERE   OF   THE   SOIL,    OR   GROUND-AIR.  135 

number  of  instances.  Among  the  latter  are  the  bacillus  of 
tetanus  (Nicolaier),  of  anthrax  (Frank),  of  malaria  (Klebs  and 
Tommasi-Crudeli),1  of  malignant  cedema  (Koch  and  Gaffky), 
and  of  typhoid  fever  (Tryde). 

It  may  not  be  inappropriate  to  refer  here  to  the  claim  of 
Professor  Domingos  Freire,  of  Brazil,  to  the  discovery  of  the 
germ  of  yellow  fever  in  the  soil  of  a  burial  ground  near  Rio 
Janeiro.  The  exhaustive  investigations  of  Surgeon-General 
G.  M.  Stern  berg,  of  the  U.  S.  Army,  under  the  direction  of  the 
government,  have  disposed  effectually  of  the  claims  and  pre- 
tensions of  the  Brazilian  scientist,  and  established  the  fact  that 
Freire's  organism  has  no  pathological  significance  whatever, — 
at  all  events,  that  it  has  no  relation  to  yellow  fever. 

Cholera  bacilli  have  not  been  found  in  the  soil,  but  C. 
Frankel  has  shown  experimentally  that  they  can  grow  and 
multiply  in  the  soil  at  various  depths.  At  a  depth  of  1^ 
metres  their  development  was  constant  and  progressive 
throughout  the  year. 

When  the  soil  is  dry,  these  organisms  may  be  carried  hither 
and  thither  in  the  movements  of  the  ground-air,  and  thus  infect 
the  air  of  contiguous  localities,  or  be  transported  to  a  distance. 

Movements  of  the  ground-atmosphere  are  principally  due 
to  differences  of  pressure  and  temperature  in  the  air  above- 
ground.  Owing  to  such  differences  the  air  from  the  soil  fre- 
quently permeates  houses,  entering  from  cellars  or  basements. 
In  winter,  when  the  air  of  houses  is  very  much  more  heated 
(and  consequently  less  dense)  than  the  air  out-of-doors, 
the  difference  of  pressure  thus  caused  draws  the  ground-air  up 
through  the  house,  while  the  cold,  external  atmosphere  pene- 
trates the  soil  and  occupies  the  place  of  the  displaced  ground- 
air.2  A  similar  effect  occurs  in  consequence  of  heavy  rains. 

1  While  the  pathogenic  significance  of  Klebs'  bacillus  malarife  is  not  generally  accepted, 
it  is  thought  proper,  for  the  sake  of  completeness,  to  include  it  among  the  organisms  sometimes 
found  in  the  soil. 

*  It  is,  of  course,  not  strictly  correct  to  say  that  the  air  is  drawn  up  through  the  house 
by  the  diminution  of  pressure ;  it  being  rather  forced  out  of  the  soil  by  the  colder  and  denser 
outside  air ;  but  the  phrase  is  sufficiently  exact  and  will  be  readily  understood. 


136  TEXT-BOOK    OF    HYGIENE. 

The  water  fills  up  the  interstices  of  the  soil  near  the  surface,  and 
forces  the  ground-air  out  at  points  where  the  pores  remain  open. 
These  places  are  the  dry  ground  under  buildings,  where  the  air 
escapes  and  passes  through  floors  and  ceilings  into  the  house 
above.  Heavy  rains  may  thus  be  the  cause  of  pollution  of  the 
air  in  houses.  The  greater  the  porosity  of  the  soil,  the  more 
likely  is  this  to  happen.  This  pollution  of  the  house-air  may 
be  prevented  by  having  impervious  floors  and  walls  to  cellars 
and  basements,  or  by  interposing  a  layer  of  charcoal  between 
the  ground  and  the  floor  of  the  house.  The  latter  does  not 
prevent  the  passage  of  the  ground-air,  but  the  charcoal  layer 
absorbs  or  arrests  the  noxious  matters, — filters  the  ground-air, 
as  it  were. 

In  the  spring  and  early  summer  the  ground  being  colder 
than  the  air  above  it,  and  the  ground-air  consequently  heavier 
and  denser,  the  latter  is  not  easily  displaced.  It  is,  perhaps, 
due  to  this  fact  that  those  infectious  diseases  which  are  proba- 
bly dependent  upon  the  movements  of  the  ground-air  are  less 
prevalent  in  the  spring  and  early  summer  than  in  the  latter 
part  of  the  summer,  autumn,  and  early  winter.  In  the  autumn 
the  ground-air  being  warmer  than  the  air  above  ground  is  easily 
displaced  by  the  latter  and  forced  out  into  the  streets  and  houses 
to  be  inspired  by  men  and  animals.  The  same  conditions  may 
explain  the  greater  likelihood  of  infection  at  night,  which  is 
proven  for  such  diseases  as  malarial  and  yellow  fevers.  The 
colder  outside  air  penetrates  the  interstices  of  the  soil  and  forces 
out  the  impure  ground-air. 

The  researches  of  Fodor  have  demonstrated  that  the  pro- 
portion of  carbon  dioxide  in  the  ground-air  may  be  taken  as  an 
approximative  measure  of  the  impurity  of  the  soil  whence  the 
air  is  taken.  The  influence  of  the  permeability  of  the  soil,  as 
before  pointed  out,  must,  however,  not  be  overlooked  in  esti- 
mating the  signification  of  the  carbon  dioxide.  Fodor  has 
shown  that  the  proportion  of  carbon  dioxide  in  the  ground-air, 
and  consequently  the  amount  of  organic  decomposition,  is 


THE    ATMOSPHERE   OP   THE    SOIL,    OR   GROUND- AIR.  137 

greatest  in  July  and  least  in  March.  That  the  carbon  dioxide 
is  derived  from  the  decomposition  of  vegetable  matter  has  been 
proven  by  Pettenkofer.  This  observer  examined  specimens  of 
air  brought  from  the  Lybian  desert,  and  found  that  the  propor- 
tion of  carbon  dioxide  in  the  ground-air  was  exactly  the  same 
as  in  the  air  collected  above-ground.  There  being  no  vegetable 
growth  in  the  desert  there  can,  of  course,  be  no  vegetable 
decomposition  going  on  in  the  soil. 

The  excess  of  carbon  dioxide  in  the  ground-air  is  an  indi- 
cation of  the  deficiency  of  oxygen,  as  has  been  shown.  The 
air  at  a  depth  of  4  metres  below  the  surface  was  found  to 
contain  only  from  7  to  10  per  cent,  of  oxygen — one-half  to  one- 
third  of  the  normal  proportion.  Many  basements  occupied  by 
pe'ople  as  living-rooms  extend  from  1  to  3  metres  under-ground, 
and  hence  are  liable  to  be  supplied  with  an  atmosphere  approach- 
ing in  impurity  that  just  mentioned.  It  requires  no  very  vivid 
imagination  to  appreciate  the  dangers  to  health  that  lurk  in  such 
habitations. 

THE   WATER   OF   THE    SOIL,    OR   GROUND-WATER. 

At  a  variable  depth  below  the  surface  of  the  ground,  a 
stratum  of  earth  or  rock  is  found  through  which  water  passes 
with  difficulty,  if  at  all.  Above  this  there  is  a  stratum  of  water 
which  moves  from  a  higher  to  a  lower  level,  and  which  varies 
in  depth  at  different  times  according  to  the  amount  of  precipita- 
tion (rain-  or  snow-  fall),  and  according  to  the  level  of  the  nearest 
body  of  water  toward  which  it  flows.  This  stratum  of  water 
is  termed  the  ground-water,  and  has  within  the  last  few  years 
assumed  considerable  importance  from  its  apparently  close  rela- 
tions to  the  spread  of  certain  of  the  infectious  diseases.  The 
direction  of  horizontal  flow  of  ground-water  is  always  toward 
the  drainage-area  of  the  district.  Thus,  it  is  usually  toward 
lakes,  rivers,  or  the  sea.  Rains,  or  a  rise  in  the  river,  cause  a 
rise  in  the  ground-water,  while  long-continued  dry  weather,  or 
a  low  stage  of  the  river  which  drains  off  the  ground-water, 


138  TEXT-BOOK   OF   HYGIENE. 

rnr.srs  a  fall  in  the  latter.  On  the  sea-coast  the  ground-water 
oscillations  probably  correspond  with  the  tides.  The  writer  is 
not  aware  of  any  observations  made  to  determine  this  point, 
with  the  exception  of  a  single  instance  mentioned  by  Dr.  De 
Chaumont.  In  Munich,  where  the  ground- water  flows  toward 
the  river  Isar,  which  divides  the  city,  it  has  been  found  that  the 
annual  range  or  oscillation  (the  difference  between  the  highest 
and  lowest  level  during  the  year)  is  3  metres,  while  the  hori- 
zontal movement  amounts  to  5  metres  per  day,  In  Buda-Pesth 
the  annual  range  was  found  by  Fodor  to  be  less  than  1  metre, 
while  in  some  portions  of  India  it  amounts  to  more  than  12 
metres.  As  it  is  from  the  ground-water  that  the  greater  portion 
of  the  supply  of  drinking-water  in  the  country  and  in  villages 
and  small  towns  is  drawn,  it  becomes  at  once  manifest  how 
important  it  is  to  prevent,  as  far  as  possible,  pollution  of  this 
source.  Cess-pools  and  manure-heaps  and  pits,  of  necessity, 
contaminate  the  soil  and  also  ground-water  for  a  distance  below 
and  around  them,  and  such  water  is  clearly  unfit  for  drinking 
and  other  domestic  purposes.  Hence,  the  reason  why  wells 
should  not  be  placed  too  near  privies  and  manure-heaps  or  pits 
becomes  apparent. 

Between  the  level  of  the  ground-water,  or  that  portion  of 
the  soil  where  its  pores  are  entirely  occupied  by  the  water — 
where,  in  other  words,  the  ground  is  saturated — and  the  surface, 
is  a  stratum  of  earth  more  or  less  moist ;  that  is  to  say,  the 
interstices  of  the  soil  are  partly  filled  with  water  and  partly  with 
air.  It  is  in  this  stratum  that  the  processes  of  organic  decay  or 
putrefaction  are  most  rapidly  going  on,  in  consequence  of  which 
the  pollution  of  the  ground-air  occurs.  The  oxidation  of  non- 
nitrogenous  matter  in  the  soil  results  in  the  formation  of  carbon 
dioxide.  On  the  other  hand,  nitrogenized  compounds  are 
oxidized  into  nitric  acid  and  nitrates.  When,  however,  putre- 
faction occurs,  nitrous  acid,  or  nitrites  and  ammonia,  are  formed, 
the  oxidation  not  proceeding  far  enough  to  result  in  nitric  acid. 

Recent  observations  seem  to  show  that  these  processes  of 


THE   WATER   OF   THE   SOIL,    OR   GROUND- WATER.  139 

decomposition  are  initiated  and  kept  up  by  minute  organisms 
termed  bacteria,  just  as  fermentation  in  liquids  containing  sugar 
can  only  take  place  in  the  presence  of  the  yeast-plant.  It  has 
been  found  that  when  non-putrefactive  decomposition  goes  on, 
there  are  always  present  multitudes  of  one  variety  of  these 
minute  organisms;  while  if  putrefactive  decomposition  is  going 
on,  a  number  of  other  varieties  of  these  organisms  are  present. 
Just  as,  when  a  fermenting  liquid  becomes  putrid,  the  yeast-plant 
disappears  and  its  place  is  taken  by  the  ordinary  bacteria  of  putre- 
faction, so  in  the  soil,  if  the  access  of  oxygen,  which  is  necessary 
to  the  life  of  the  bacteria  of  decay,  is  prevented,  these  organisms 
die*  and  are  succeeded  by  the  organisms  of  putrefaction.  It  has 
been  found  that  in  a  soil  saturated  with  water  the  bacteria  of  decay 
cannot  live,  while  those  of  putrefaction  may  flourish,  because 
these  latter  organisms  can  sustain  life  and  develop  in  the 
absence  of  oxygen.  Professor  Fodor's  researches  indicate  that 
the  most  prominent  organism  of  non-putrefactive  decomposition 
or  decay  is  that  which  is  termed  by  Cohn  bacterium  lineola;  and 
that  the  bacterium  termo  is  the  principal  organism  of  putrefaction. 

DISEASES   SPREAD   BY   SOIL   IMPURITIES. 

Given  now  an  area  of  soil,  say  the  ground  upon  which  a 
house  or  city  is  built,  with  a  moist  stratum  in  which  the  pro- 
cesses of  decay  are  active,  and  imagine  a  rise  in  the  ground- 
water.  The  ground-air,  charged  with  carbon  dioxide  and  other 
products  of  decomposition,  is  forced  out  of  the  pores  of  the  soil 
by  the  rising  ground-water,  and  escapes  into  the  external  air, 
or  through  cellars  and  basements  into  houses,  and  may  there 
produce  disease.  But  the  saturation  of  the  soil  with  water  pre- 
vents the  further  development  of  the  bacteria  of  decay,  and  this  is 
checked,  or  putrefaction  may  take  place.  If  now  the  ground- 
water  sinks  to  its  former  level  or  below,  the  processes  of  decay 
again  become  very  active  in  the  moist  stratum,  and  large  quan- 
tities of  carbon  dioxide  and  other  inorganic  compounds  are 
produced.  If  the  germs  of  infectious  or  contagious  diseases 


140  TEXT-BOOK   OF   HYGIENE. 

have  been  introduced  into  the  soil,  they  also  multiply  and  may 
escape  with  the  movements  of  the  ground-air  into  the  external 
atmosphere,  and  there  produce  their  infective  action.  This,  it  is 
held  by  Pettenkofer  and  his  followers,  is  what  actually  occurs  in 
cholera  and  typhoid  fever.  Professor  DeChaumont  has  laid 
down  the  rule  that  a  soil  with  a  persistently  low  stage  of  ground- 
water,  say  5  metres  below  the  surface  of  the  ground,  is  healthy ; 
a  persistently  high  stage  of  ground- water,  less  than  1 J  metres 
below  the  surface,  is  unhealthy ;  while  a  fluctuating  level  of  the 
ground-water,  especially  if  the  changes  are  sudden  and  violent, 
is  very  unhealthy.  This  would  lead  us  to  expect  that  places 
where  this  fluctuation  is  very  great  would  show  a  large  mortality 
from  such  diseases  as  are  attributed  to  impurities  in  the  soil. 
And  this  we  find  especially  true  in  India.  In  certain  localities 
in  India,  cholera,  for  example,  is  endemic ;  that  is  to  say,  the 
disease  is  never  entirely  absent  in  such  localities.  Calcutta  is 
one  of  these  places.  The  rainy  season  begins  about  the  first  of 
May  and  continues  until  the  end  of  October.  During  the  next 
six  months  there  is  very  little  rain.  It  is  fair  to  assume  that 
the  ground-water  rises  during  the  rainy  season  and  checks  decay 
and  the  multiplication  of  the  germs  of  the  disease  in  the  soil, 
and  that  these  processes  become  more  active  as  the  dry  season 
advances  and  the  ground-water  level  falls.  If  we  note  the 
death-rate  from  cholera  in  Calcu£ta  it  will  be  found  that  it  bears 
a  distinct  relation  to  the  movement  of  the  ground-water.  The 
deaths  from  cholera  begin  to  increase  from  October  and  reach 
their  height  in  April.  Dr.  Macpherson,  who  has  written  a  very 
elaborate  history  of  Asiatic  cholera,  shows  this  relation  very 
clearly.  For  twenty-six  years  the  average  rain-fall  was  157  cen- 
timetres. From  May  to  October  1 42  centimetres  fell,  while  the 
remaining  15  centimetres  fell  from  November  to  April.  The 
average  number  of  deaths  from  cholera  annually  was  4013. 
Of  these,  1238  died  in  the  rainy  season,  while  2775,  nearly 
three-fourths,  died  during  the  period  of  dry  weather. 

In  the  cholera  epidemics  of  1866  and  1873  in  Buda-Pesth, 


DISEASES   SPREAD   BY   SOIL   IMPURITIES.  141 

the  same  relations  existed  between  the  ground- water  and  the 
cholera.  As  the  level  of  the  ground-water  rose  the  cholera 
diminished,  while  the  disease  increased  upon  the  sinking  of  the 
ground-water.  Exactly  the  same  behavior  was  exhibited  by  the 
disease  in  Munich  in  1873. 

There  seems  good  reason  to  believe  that  typhoid  fever  is 
propagated  in  consequence  of  movements  of  the  ground-water, 
in  the  same  way  as  above  explained  for  cholera.  This  does  not 
exclude  the  infection  of  drinking-water  by  the  disease-germ, 
since  much  of  the  drinking-water  used,  as  before  stated,  is  drawn 
from  the  ground-water.  Pettenkofer,  Buhl,  and  Virchow  have 
shown  that  the  death-rate  from  typhoid  fever  has  a  distinct  and 
definite  relation  to  the  ground- water  oscillations.  This  has  been 
incontestably  proven  for  two  cities,  Munich  and  Berlin.  When 
the  level  of  the  ground-water  is  above  the  average,  typhoid  fever 
decreases;  when  it  is  below  the  average,  the  number  of  cases 
becomes  greater.  Dr.  H.  B.  Baker  has  demonstrated  that  the 
fluctuation  of  the  ground-water  level  in  the  State  of  Michigan 
is  similarly  followed  by  a  change  in  the  morbility  and  mortality 
from  typhoid  fever.1  Hence,  it  may  be  regarded  as  an  established 
law  that  the  rise  and  fall  of  the  ground-water  bears  a  definite 
relation  to  the  morbility  rate  of  typhoid  fever. 

Nearly  thirty  years  ago  Dr.  Henry  I.  Bowditch,  of  Boston, 
called  attention  to  the  frequent  connection  between  cases  of 
pulmonary  consumption  and  dampness  of  the  soil  upon  which 
the  patients  lived.  After  a  very  extended  and  laborious  investi- 
gation Dr.  Bowditch  formulated  these  two  propositions: — 

"  First. — A  residence  in  or  near  a  damp  soil,  whether  that 
dampness  be  inherent  in  the  soil  itself  or  caused  by  percolation 
from  adjacent  ponds,  rivers,  meadows,  or  springy  soils,  is  one  of 
the  principal  causes  of  consumption  in  Massachusetts,  probably 
in  New  England,  and  possibly  other  portions  of  the  globe. 

"  Second. — Consumption  can  be  checked  in  its  career,  and 

1  The  Relation  of  the  Depth  of  Water  in  Wells  to  the  Causation  of  Typhoid  Fever, 
Public  Health,  vol.  x,  p.  184-213. 


142  TEXT-BOOK   OF   HYGIENE. 

possibly — nay,  probably — prevented  in  some  instances  by  atten- 
tion to  this  law."1 

Dr.  Buchanan,  of  England,  about  the  same  time  showed 
that  the  thorough  drainage  of  certain  English  cities  had  mark- 
edly diminished  the  deaths  from  consumption  in  the  drained 
cities.  So  far  as  the  writer  is  aware,  not  a  single  fact  has  been 
established  which  militates  against  the  law  laid  down  by  Dr. 
Bowditch,  and  so  strongly  supported  by  the  statistical  researches 
of  Dr.  Buchanan,  yet  hardly  any  notice  has  been  taken  of  these 
results  by  physicians.  Few  know  anything  of  them,  and  still 
fewer  seem  to  have  made  practical  use  of  such  knowledge  in 
advising  patients.  As  corroborative  of  the  views  of  Dr.  Bow- 
ditch,  the  rarity  of  consumption  in  high  and  dry  mountainous 
districts  or  plateaus  may  be  cited. 

A  recent  study  of  the  topographical  distribution  of  con- 
sumption in  the  State  of  Pennsylvania,  by  Dr.  William  Pepper, 
apparently  confirms  Dr.  Bowditch's  conclusions  in  nearly  every 
particular.  It  is  now  known  that  the  direct  cause  of  consump- 
tion is  the  bacillus  tuberculosis,  discovered  by  Dr.  Robert  Koch. 
The  relation  between  soil-moisture  and  the  increase  of  consump- 
tion will  probably  be  found  in  the  more  favorable  conditions 
of  development  of  the  tubercle  bacillus  furnished  by  a  moist 
medium. 

DISEASES    OF   ANIMALS    PROBABLY   DUE   TO   SIMILAR   CONDITIONS    OF 

THE    SOIL. 

The  modern  study  of  the  sanitary  relations  of  the  soil  is 
still  in  its  infancy.  Whatever  definite  knowledge  has  been 
gained  relates  merely  to  physical  or  chemical  conditions  of  the 
soil  and  its  atmosphere  and  moisture,  or  possibly  the  relations 
of  these  to  the  spread  of  certain  diseases  in  human  beings.  But 
there  is,  perhaps,  a  wider  application  that  may  be  made  of  such 
knowledge  than  has  been  heretofore  suggested.  The  domestic 
animals  which  form  such  a  large  portion  of  the  wealth  of  this 

>  Consumption  in  New  England  and  Elsewhere,  2d  eel.,  p.  87.    Boston,  1866. 


DISEASES  OF  ANIMALS  DUE  TO  SIMILAR  CONDITIONS  OF  SOIL.       143 

country — horses,  cattle,  sheep,  and  hogs — are  liable  to  infectious 
and  contagious  diseases,  as  well  as  are  human  beings,  and  many 
millions  of  dollars  are  lost  annually  by  the  ravages  of  such 
diseases.  Now,  from  what  is  known  of  such  diseases  as  splenic 
fever  among  cattle,  and  of  the  so-caUed  swine  plague,  it  does 
not  appear  improbable  to  the  writer  that  the  source  of  infection 
is  a  soil  polluted  by  the  poisonous  germ  of  these  diseases,  just 
as  it  seems  demonstrated  that  cholera  and  typhoid  fever  and 
possibly  malarial  fevers  are  so  caused.  The  laborious  investiga- 
tions of  M.  Pasteur  in  France  have  shown  that  the  cause  of 
splenic  fever,  when  once  introduced  into  a  locality,  will  remain 
active  for  months,  and  even  years,  and  it  seems  probable  that  a 
study  of  the  soil  in  its  relations  to  the  diseases  of  domestic 
animals  is  a  subject  to  which  attention  may  profitably  be 
given. 

It  is  well  known  that  milch-cows  frequently  suffer  from  a 
disease  identical  in  its  nature  with  consumption  in  human 
beings.  It  is  believed  by  many  that  the  milk  of  such  animals 
is  not  only  unfit  for  food  by  reason  of  its  poor  quality,  but  that 
it  may  convey  the  disease  to  human  beings  when  used  as  food. 
The  observations  of  Bowditch  and  Buchanan,  quoted  above, 
show  that  consumption  in  man  may  be,  and  doubtless  is, 
frequently  caused  by  soil-wetness.  It  seems  probable  that  the 
same  cause  should  produce  similar  effects  in  the  lower  animals, 
and  it  is  the  writer's  firm  conviction  that  an  examination  into 
the  circumstances  under  which  cows  become  attacked  by  con- 
sumption would  prove  this  probability  a  fact. 

DRAINAGE. 

In  many  soils  drainage  is  necessary  in  order  to  secure  a 
constant  level  of  the  ground-water  at  a  sufficient  depth  below 
the  surface.  Drainage  and  sewerage  must  not  be  confounded 
with  each  other.  Drainage  contemplates  only  the  removal  of 
the  ground-water,  or  the  reduction  of  its  level,  while  sewerage 
aims  to  remove  the  refuse  from  dwellings  and  manufactories, 


144  TEXT-BOOK   OF   HYGIENE. 

including  excrementitious  matters,  waste-water,  and  other 
products,  and  in  some  cases  the  storm-water. 

Sewers  should  never  be  used  as  drains,  although  for 
economy's  sake  sewer-  and  drainage-  pipes  may  be  laid  in  the 
same  trench.  Sewer-pipe  must  be  perfectly  air-tight  and  water- 
tight to  prevent  escape  of  its  liquid  or  gaseous  contents  into  the 
surrounding  soil  and  rendering  it  impure.  Drainage-pipe,  on 
the  other  hand,  should  be  porous  and  admit  water  freely  from 
without.  Escape  of  the  contents  of  the  drain-pipe  into  the 
surrounding  soil  will  not  produce  any  pollution  of  the  latter. 

The  best  material  for  drains  is  porous  earthenware  pipe,  or 
the  ordinary  agricultural  drain-tile.  Coarse  gravel  or  broken 
stones  may  also  be  used,  and  prove  efficient  if  the  drains  are 
properly  constructed.  Referring  again  to  the  aphorism  of 
Professor  DeChaumont,  that  a  persistently  low  ground-water, 
say  5  metres  down,  or  more,  is  healthy;  that  a  persistently  high 
ground-water,  less  than  1 1  metres  from  the  surface  is  unhealthy ; 
and' that  a  fluctuating  level,  especially  if  the  changes  are  sudden 
and  violent,  is  very  unhealthy,  the  necessity  appears  obvious 
that  in  the  construction  of  drainage-works  the  drains  should  be 
placed  at  a  sufficient  depth  to  secure  a  level  of  the  ground-water 
consistent  with  health.  This  depth  should  never  be  less  than 
3  metres,  and,  if  possible,  not  less  than  5  metres.  Care  must  be 
taken  that  the  outflow  of  the  drain  is  unobstructed,  in  order 
that  the  soil  may  be  kept  properly  dry  at  all  times. 

In  the  absence  of  a  proper  mechanical  system  of  drainage, 
the  planting  of  certain  trees  may  efficiently  drain  the  soil.  It 
has  been  found  that  the  eucalyptus  tree  has  produced  drying  of 
the  soil  when  planted  in  sufficient  numbers  in  marshy  land. 
The  roots  absorb  a  prodigious  quantity  of  water,  which  is  then 
given  off  by  evaporation  from  the  leaves.  Sunflower-plants  have 
a  similar  effect  upon  wet  soils. 


QUESTIONS   TO   CHAPTER  IV. 

THE  SOIL. 

Why  is  it  necessary  to  possess  a  knowledge  of  the  physical  and 
chemical  conditions  of  the  soil  ?  What  substances  are  included  in  the 
consideration  of  soils  ?  Of  what  is  the  surface  soil  composed  ?  How 
do  soils  vary  in  composition,  physically  and  chemically  ? 

What  occupies  the  interstices  of  the  soil  ?  Upon  what  does  the 
proportion  of  air  in  the  soil  depend  ?  Is  this  proportion  comparatively 
great  or  small?  What  relation  has  the  soil-air  to  the  atmospheric  air, 
and  what  causes  the  difference  in  composition  ?  In  what  way  does  the 
soil-air  differ  from  the  atmospheric  air  ?  Has  the  soil-air  an}'  definite 
composition  ?  What  are  the  factors  governing  the  variation  in  composi- 
tion ?  What  kind  of  a  soil  will  be  likely  to  contain  most  carbon  dioxide 
and  least  oxygen  ?  What  does  this  indicate  ?  What  micro-organisms 
are  always  to  be  found  in  the  soil-air?  What  pathogenic  organisms 
may  also  make  the  soil  and  soil-air  their  habitat  ?  How  may  these  be 
carried  from  place  to  place  ?  To  what  are  movements  of  the  ground-air 
due?  How  may  this  soil-air  gain  access  to  our  houses,  and  what  meas- 
ures should  be  taken  to  prevent  its  entrance?  When  is  the  danger 
greatest  ?  Why  are  certain  infectious  diseases  less  prevalent  in  spring 
and  early  summer  than  in  autumn?  Why  is  there  greater  danger  of 
infection  from  these  diseases  at  night  than  in  the  day -time?  Is  the 
carbon  dioxide  of  the  soil-air  a  measure  of  the  impurity  of  the  soil  ? 
What  causes  the  excess  of  carbon  dioxide  ?  When  is  the  proportion  of 
carbon  dioxide  greatest?  Why  are  living-apartments  below  the  surface 
01  the  ground  very  apt  to  be  unhealthy  ? 

What  is  meant  by  the  term  "ground-water"?  Where  is  it  to  be 
found?  Has  it  a  definite  current?  In  what  direction  is  the  flow? 
Upon  what  does  the  level  of  the  ground-water  depend  ?  What  class  of 
the  population  derive  their  drinking-water  largely  from  the  ground- 
water  ?  What  are  some  of  the  sources  of  contamination  of  the  ground- 
water  ?  What  are  some  of  the  deductions  to  be  made  accordingly  ? 

In  what  part  of  the  soil  do  the  processes  of  organic  decay  and  putre- 
faction occur  most  readily?  What  are  the  causes  of  these  processes? 
What  are  some  of  their  products?  What  is  the  distinction  between 
non-putrefactive  decomposition  or  deca}-  and  putrefaction  ? 

10  (145) 


146  QUESTIONS   TO    CHAPTER    IV. 

How  m&y  disease  be  spread  by  the  rise  and  fall  of  the  ground-water? 
What  two  infective  diseases  are  especially  apt  to  be  transmitted  in  this 
way?  Give  instances  that  tend  to  prove  this.  Upon  what  other  dis- 
ease has  a  damp  soil  a  directly  causative  influence  ?  What  diseases  of 
animals  are  likely  to  be  influenced  in  a  similar  manner?  How  deep 
below  the  surface  should  the  soil-water  persistently  be  that  the  soil  may 
be  healthy  ?  What  effect  upon  health  has  a  suddenly  and  markedly 
fluctuating  soil-water  ?  Is  a  soil  with  its  water  persistently  near  the 
surface  apt  to  be  health}'  ? 

What  do  we  mean  by  drainage,  and  what  is  its  object  and  function  ? 
What  is  the  difference  between  it  and  sewerage?  How  should  drains  be 
laid  ?  What  is  the  best  material  for  drains  ?  What  precautions  must 
be  observed  in  the  laying  of  drains?  How  may  the  surplus  water  be 
taken  from  the  soil  otherwise  than  by  drains  ? 


CHAPTER  V. 

REMOVAL  OF  SEWAGE. 

IN  all  larger  communities  certain  arrangements  are  neces- 
sary to  secure  a  prompt  and  efficient  removal  of  excreta  and 
the  refuse  and  used  water  of  households  and  manufacturing 
establishments,  the  sweepings  of  streets,  and  rain-water. 

The  total  quantity  of  excrementitious  products— faeces  and 
urine — for  each  individual,  including  men,  women,  and  children, 
has  been  estimated  by  Professor  von  Pettenkofer  as  90  grammes 
of  faecal  and  1170  grammes  of  urinary  discharge  daily.  This 
would  give  for  a  population  of  1000  persons  34,000  kilogrammes 
of  faeces  and  428,000  litres  of  urine  per  year.  If  to  this  is 
added  a  minimum  allowance  of  159  litres  of  water  per  day  to 
each  individual,  a  complete  sewerage  system  for  a  population 
of  1000  persons  would  require  provision  for  the  discharge  of 
160,000  litres  of  sewage  passing  through  the  sewers  every  day. 
In  this  estimate  storm-water  and  such  accessory  feeders  of  the 
sewage  are  omitted. 

The  organic  matters  contained  in  sewage,  even  if  free  from 
the  specific  germs  of  disease,  give  rise  to  noxious  emanations, 
which,  when  inhaled,  probably  produce  a  gradual  depravement 
of  nutrition  that  renders  the  system  an  easier  prey  to  disease. 
For  this  and  other  reasons  it  is  important  that  such  measures  be 
adopted  as  will  secure  the  removal  of  sewage  matters  from  the 
immediate  vicinage  of  houses  as  quickly  as  possible  after  they 
have  been  discharged. 

The  impregnation  of  the  soil  with  sewage  produces  a  con- 
tamination of  ground-air  and  ground-water,  which  may  become 
a  source  of  grave  danger  to  health.  By  polluting  the  ground- 
water  it  eventually  vitiates  the  well-water,  which  is  nearly  always 
derived  from  that  source. 

(147) 


148  TEXT-BOOK   OF   HYGIENE. 

The  system  of  removal  of  excrementitious  matters  which 
any  community  will  adopt  depends  to  a  considerable  extent  upon 
financial  considerations.  Although  the  sanitarian  must  insist 
upon  the  pre-eminent  importance  of  the  cause  of  public  health, 
his  suggestions  will  receive  little  attention  from  municipal  or 
state  legislatures  unless  they  can  be  carried  out  without  involv- 
ing the  community  too  deeply  in  debt.  For  this  reason  it  is  a 
matter  of  great  practical  importance  that  the  student  of  sani- 
tary science  should  make  himself  familiar  with  the  relative  cost 
as  well  as  with  the  hygienic  significance  of  the  various  methods 
of  sewage  removal  in  use. 

The  different  systems  in  use  for  the  removal  of  sewage 
matters  may  be  considered  in  detail  under  the  following  five 
heads: — 

1.  The  common  privy,  or  privy- vault  systems. 

2.  The  Rochdale  or  pail  system,  and  its  modifications. 

3.  The  earth-  or  ash-  closet  system. 

4.  The  pneumatic  system  of  Liernur. 

5.  The  water-carriage  systems. 

1.  The  Privy  and  Privy-well  Systems. — While  from  a 
sanitary  point  of  view  privies  of  all  kinds,  whether  wells  or 
cess-pits,  are  to  be  unreservedly  condemned,  it  is  not  likely  that 
they  will  cease  to  be  built  for  many  years  to  come.  It  becomes 
necessary,  therefore,  to  point  out  by  what  means  the  objections 
against  them  may  be  diminished,  and  their  evil  consequences  in 
some  measure  averted. 

In  the  first  place,  a  privy- vault  should  be  perfectly  water- 
tight in  order  to  prevent  pollution  of  the  surrounding  soil  by 
transudation  of  the  contained  excremental  matters.  The  walls 
should  be  of  hard-burned  brick  laid  in  cement.  The  cavity 
should  be  small  in  order  that  the  contents  may  be  frequently  re- 
moved, and  not  allowed  to  remain  and  putrefy  for  months  or 
years.  A  water-tight  hogshead  sunk  in  the  ground  makes  an 
economical  privy-tank  or  receiver.  A  privy  must  not  be  dug  in 
a  cellar,  or  in  too  close  proximity  to  the  house-walls.  Unless 


REMOVAL   OF    SEWAGE.  149 

these  last  precautions  are  taken  the  offensive  gases  from  the 
mass  of  decomposing  faecal  matter  in  the  privy  will  constantly 
ascend  into  and  permeate  the  air  of  the  house. 

All  privies  should  be  ventilated  by  a  pipe  passing  from  just 
under  the  privy-seat  to  a  height  of  about  a  metre  above  the 
roof  of  the  house.  A  gas-flame,  kept  burning  in  the  upper  portion 
of  this  pipe,  will  increase  its  ventilating  power  by  creating  a 
strong  and  constant  upward  current. 

Deodorization  of  the  contents  of  privies  may  be  secured  in 
a  measure  by  means  of  sulphate  of  iron,  phenyle,  carbolic  acid, 
or  dry  earth.  The  first  named  is  probably  the  most  economical, 
most  easily  applied,  and  very  effective.  A  solution  containing 
from  |  to  1  kilogramme  of  the  salt  in  4  litres  of  water  is  poured 
into  the  privy  as  often  as  necessary  to  prevent  offensive  odors. 
This  solution  may  be  conveniently  prepared  by  suspending  a 
basket  or  bag  containing  about  25  kilogrammes  of  the  sulphate 
in  a  barrel  of  water.  In  this  way  a  saturated  solution  will  be 
maintained  until  the  salt  has  been  entirely  dissolved.  Phenyle 
is  likewise  a  good  deodorizer  as  well  as  an  excellent  disinfectant. 

The  most  rigid  deodorization  by  chemicals  will,  however, 
be  less  effective  than  thorough  ventilation,  for  it  must  be  re- 
membered that  the  mere  destruction  of  an  offensive  odor  is  not 
equivalent  to  removing  all  the  deleterious  properties  that  may 
be  present.  It  is  not  at  all  certain  that  those  elements  of  sew- 
age which  are  the  most  offensive  to  the  sense  of  smell  are  most 
detrimental  to  health. 

Privies  should  be  emptied  of  their  contents  at  stated  inter- 
vals. A  strict  supervision  should  be  exercised  over  them  by  the 
municipal  authorities  in  cities  and  towns  to  prevent  overflowing 
of  their  contents. 

In  many  places  the  method  of  removing  the  contents  of 
privies  is  the  primitive  one  with  shovel,  or  dipper  and  bucket. 
In  most  cities  and  large  towns,  however,  the  privy-vaults  or  tanks 
are  now  emptied  by  means  of  one  of  the  so-called  odorless  excavat- 
ing machines,  of  which  there  are  a  number  of  different  patents. 


150  TEXT-BOOK   OF   HYGIENE. 

The  process  is  rarely  entirely  odorless,  however,  as  the  careless- 
ness of  the  workmen  frequently  permits  offensive  gases  to  escape 
and  pollute  the  air  for  a  considerable  distance.  All  the  different 
forms  of  the  apparatus  act  upon  the  pneumatic  principle.  One 
end  of  a  large  tube  is  carried  into  the  cess-pool  or  vault  to  be 
emptied  and  the  other  attached  to  a  pump,  by  means  of  which 
the  material  is  pumped  into  a  strong  barrel-tank  carried  on 
wheels.  At  the  top  of  the  tank  is  a  vent,  over  which  is  placed 
a  small  charcoal  furnace  to  consume  the  foul  gases  escaping 
from  the  vent. 

In  some  cities  and  many  of  the  smaller  towns  and  villages 
in  this  country  the  primitive  midden  or  pit  system  is  still  in  use. 
A  shallow  pit  is  dug  in  the  ground,  over  which  is  erected  the 
privy.  When  the  pit  is  full  another  is  dug  close  by  the  side  of 
it,  and  the  earth  from  the  new  pit  thrown  upon  the  excrement 
in  the  old  one.  The  privy  is  then  moved  over  the  new  pit,  and 
this  is  used  until  it  too  becomes  full.  The  proceeding  is  re- 
peated as  often  as  the  pit  becomes  filled  up  with  the  excreta, 
until  in  the  course  of  a  few  years  all  the  available  space  in  a 
yard  has  been  honey-combed  with  the  pits.  Then  the  custom 
adopted  in  overcrowded  cemeteries  is  followed,  namely,  the  first 
pit  is  dug  out  again  and  the  cycle  is  repeated. 

In  other  cities  the  privy-well  system  is  largely  in  use.  This 
is — next  to  the  midden  or  shallow  pit  just  described — the  most 
pernicious  system  for  the  disposal  of  excreta  that  can  be 
imagined.  The  wells  are  dug  to  such  a  depth  as  to  reach  the 
subterranean  now  of  water,  in  which  the  soluble  excremental 
matters  are  constantly  carried  off.  Hence  these  receptacles  rarely 
fill  up  or  need  cleaning.  For  this  reason  they  are  popular  with 
property  owners  ;  for,  next  to  the  primitive  midden,  they  are  the 
most  economical  of  all  the  various  methods  adopted.  The  utter 
pemiciousness  of  the  system  is,  however,  plain,  because  the  soil 
for  a  considerable  distance  around  each  of  these  wells  becomes 
a  mass  of  putrid  filth,  contaminating  the  ground-water  which 
feeds  the  drinking- water  supplies  in  the  vicinity ;  polluting  also 


REMOVAL   OF   SEWAGE.  151 

the  ground-air,  which  eventually  reaches  the  surface,  or  the  in- 
terior of  houses,  when  the  pressure  of  the  outside  atmosphere 
diminishes  or  the  ground-water  level  rises.  It  must,  therefore, 
be  evident  that  the  best  ventilating  arrangements,  or  the  most 
thorough  and  consistent  disinfection,  can  have  very  little,  if  any, 
effect  in  removing  the  very  grave  objections  to  this  baneful 
system. 

The  privy-well  system  for  the  removal  of  excreta  cannot  be 
recommended  for  adoption  by  any  sanitarian. 

2.  The  Rochdale,  or  Pail-closet  System. — The  Rochdale 
system  of  removal  of  excreta  has  won  the  support  of  many  dis- 
tinguished sanitarians  on  account  of  its  simplicity,  its  economy, 
and  its  compliance  with  most  sanitary  requirements.  The  ex- 
creta, both  solid  and  liquid,  are  received  into  a  water-tight  pail, 
either  of  wood  or  metal,  and  removed  once  or  oftener  a  week, 
a  clean  and  disinfected  pail  being  substituted  for  the  one 
removed.  In  Rochdale,  Manchester,  and  Glasgow  in  Great 
Britain,  in  Heidelberg  in  Germany,  and  in  other  cities  abroad, 
where  this  system  has  been  introduced,  it  has  worked  satisfac- 
torily. In  this  country  a  modification  of  the  pail  system,  known 
as  the  Eagle  Sanitary  Closet,  has  been  introduced  by  a  firm  in 
Charleston,  S.  C.  The  receptacle  consists  of  an  enameled-iron 
reservoir,  with  a  neck  just  large  enough  to  fit  under  the  seat  of 
the  privy,  and  a  quantity  of  disinfectant  solution  is  put  into  the 
receptacle  to  prevent  putrefaction  of  the  excreta.  The  recep- 
tacles are  replaced  by  clean  ones  every  week. 

Mr.  James  T.  Gardner,  Director  of  the  New  York  State 
Sanitary  Survey,  says,  in  a  special  report  on  methods  of  sewerage 
applicable  in  small  towns  and  villages,  concerning  the  pail 
system1 : — 

"  Rochdale  is  a  city  of  some  70,000,  and  Manchester  of 
between  400,000  and  500,000  inhabitants.  The  higher  class 
of  houses  are  allowed  to  have  water-closets,  but  four-fifths  of 
the  people  are  obliged  to  have  '  pail-closets  '  in  their  yards  built 

1  Second  Annual  Report  of  New  York  State  Board  of  Health,  pp.  322,  323. 


152  TEXT-BOOK   OF   HYGIENE. 

according  to  plans  of  the  Health  Department.  Their  essential 
features  are :  A  flag-stone  floor,  raised  a  few  inches  above  the 
level  of  the  yard ;  a  hinged  seat,  with  a  metal  rim  underneath 
for  directing  urine  into  the  pail,  which  stands  on  the  flag  directly 
beneath  the  seat ;  a  hinged  front  and  back  to  the  seat,  so  that 
the  pail  or  tub  may  be  easily  taken  out  and  the  place  cleaned ; 
and  a  6-inch  ventilating  pipe  from  under  the  seat  to  above  the 
roof.  In  Rochdale  they  use  a  wooden  pail  or  tub  made  of  half 
of  a  disused  paraffine  cask,  holding  about  40  kilogrammes ;  in 
Manchester  the  '  pail '  is  of  galvanized  iron  and  holds  40  litres. 
Under  the  direction  of  the  authorities,  they  are  removed  once  a 
week  in  covered  vans,  which  bring  clean  tubs  to  be  put  in  the 
place  of  the  full  ones  taken  away.  Each  tub  is  covered  with  a 
close-fitting  double  lid  before  removal.  The  tubs  are  taken  to  a 
depot,  where  their  contents  are  deodorized  and  prepared  as 
manure  by  mixing  with  ashes  and  a  small  proportion  of  gypsum 
to  fix  the  ammonia.  Subsequently,  street-sweepings  and  the 
refuse  of  slaughter-houses  are  added.  At  Manchester  there  is 
by  the  side  of  each  closet  a  very  simple  ash-sifter,  from  which 
the  ashes  fall  into  the  tub  and  help  to  deodorize  its  contents. 

"  The  manure  at  Rochdale  sells  for  about  four-fifths  of  the 
cost  of  the  collection  and  preparation. 

"  In  1873  the  net  cost  to  the  town  of  removing  and  dispos- 
ing of  the  house  dry  refuse  and  excrement  was  only  about  $95 
per  annum  per  1000  of  population, — less  than  10*cents  a  person 
per  annum. 

"  The  system  has  been  in  operation  more  than  twelve  years. 

"  The  tubs  are  removed  in  the  day-time  without  offensive 
odor! 

"  Where  ashes  are  frequently  thrown  into  the  tubs  at  Man- 
chester, very  little  odor  is  to  be  perceived  in  the  closets. 

"  For  the  villages  of  the  State,  which  can  have  no  general 
water-supply,  I  would  unhesitatingly  advise  the  use  of  the 
'  pail '  or  tub  system  as  practiced  in  Manchester,  England,  as 
being,  from  a  sanitary  point  of  view,  an  immense  improvement 


REMOVAL   OF   SEWAGE.  153 

over  the  death-breeding  privy-vaults  in  common  use.  The 
cheapness  of  the  plan  and  the  small  ness  of  the  original  outlay 
of  brains  and  money,  in  comparison  with  that  needed  to  build 
a  good  sewer  system,  will  make  it  possible  to  introduce  a  tub- 
privy  system  into  most  villages  half  a  century  before  sewers 
would  meet  with  any  consideration. 

"  At  a  small  cost  the  existing  privy- vaults  can  be  cleaned 
and  filled,  and  the  privies  altered  into  healthful  tub-closets.  The 
town  authorities  must  then  arrange  for  the  removal  of  the  tubs 
once  a  week,  and  for  their  thorough  cleansing  and  disinfecting. 
Any  isolated  house,  or  group  of  houses,  can  use  the  tub  system, 
taking  care  of  it  themselves.  If  the  plan  is  adopted  in  villages 
it  will  doubtless  spread  into  the  country,  and  become  the  most 
powerful  means  of  abolishing  the  fatal  privy-vaults  which  are 
poisoning  the  farm-wells." 

3.  Earth-  and  Ash-  Closets. — The  earth-  and  ash-  closets 
are  devices  in  use  to  a  large  extent  in  England,  and  to  a  less 
degree  in  this  country,  for  the  purpose  of  rendering  human  ex- 
creta inodorous  by  covering  them  immediately  after  they  are 
voided  with  dry  earth  or  ashes.  The  earth-closet  is  the  inven- 
tion of  the  Rev.  Henry  Moule,  of  England,  and  consists  of  an 
ordinary  commode  or  closet,  the  essential  feature  of  which  is  a 
reservoir  containing  dried  earth  or  ashes,  a  quantity  of  which, 
amounting  to  about  twice  the  quantity  of  fasces  voided,  is  thrown 
upon  the  evacuation  either  by  hand  or  by  means  of  an  auto- 
matic apparatus  called  a  "chucker."  Just  as  in  the  ordinary 
water-closet,  by  raising  a  handle  a  supply  of  water  is  thrown 
into  the  hopper  to  wash  down  the  faeces  into  the  soil-pipe,  so,  in 
the  usual  form  of  the  earth-closet,  raising  the  handle  projects  a 
quantity  of  earth  upon  the  evacuated  faeces  and  urine.  By  this 
means  the  excreta  are  rendered  entirely  inodorous  and  dry. 
The  contents  of  the  closets  may  be  collected  into  a  heap  in  a 
dry  place.  In  the  course  of  a  few  months  the  organic  constit- 
uents have  become  oxidized,  and  the  earth  may  be  used  over 
again  for  a  number  of  times.  A  well-known  sanitarian  states 


154 


TEXT-BOOK   OF   HYGIENE. 


that  he  has  used  sifted  anthracite  coal-ashes  ten  or  twelve  times 
over  in  the  course  of  three  years.  During  this  time  the  material 
under  no  circumstances  gave  any  indication  that  it  was  "  any- 
thing but  ashes,  with  a  slight  admixture  of  garden  soil."1 

'  Dr.  Buchanan,  of  England,  comparing  the  advantages  of 
the  earth-closet  with  those  of  the  water-closet,  says:  "It  is 
cheaper  in  original  cost ;  it  requires  less  repairs ;  it  is  not  in- 
jured by  frost ;  it  is  not  damaged  by  improper  substances  being 


FIG.  4.  — PULL-UP  HANDLE  COMMODE, 
SHOWING  THE  DOOR  OPEN  FOR'  REMOV- 
ING PAIL.  THE  FLAP  OF  THE  SEAT 
AND  EARTH-RESERVOIR  ARE  ALSO  PAR- 
TIALLY RAISED  TO  SHOW  THE  CON- 
STRUCTION. 


FIG.  5.— S  HOAVING  THE  APPARATUS 
MOUNTED  ON  BEARERS  AS  WHEN 
FIXED.  SEAT  REMOVED,  SHOWING  ME- 
CHANICAL ARRANGEMENT. 


thrown  down  it ;  and  it  very  greatly  reduces  the  quantity  of 
water  required  by  each  household."2 

In  cities  and  towns  the  removal  of  the  excreta  should  be 
carried  out  by  or  under  the  immediate  direction  of  the  mu- 
nicipal sanitary  authorities.  If  this  is  neglected,  abuses  are 
liable  to  creep  in  which  will  vitiate  the  performance  of  any 
system,  however  faultless,  when  properly  managed. 

Many  advocates  of  the  pail,  dry  earth,  or  privy  systems  urge 
the  advantage  of  the  large  quantity  of  valuable  manure  which 

1  The  Sanitary  Drainage  of  Houses  and  Towns,  Waring,  p.  250.    2d  ed.,  1881. 

2  Quoted  in  Waring,  above  cited,  p.  264. 


REMOVAL   OF   SEWAGE.  155 

can  be  realized  by  converting  the  excremental  matters  into  pou- 
drette  and  other  fertilizing  compounds.  Experience  has  shown, 
however,  that  the  cost  of  preparing  a  satisfactory  fertilizer  from 
human  excrement  is  much  greater  than  can  be  realized  from  its 
sale.  In  all  places  in  Great  Britain  and  the  continent  of  Europe 
where  it  has  been  tried  the  decision  is  against  its  practicability. 
The  agricultural  consideration  should,  however,  be  a  secondary 
one,  if  the  systems  mentioned  are  economical  and  meet  the 
sanitary  requirements  (which  the  privy  system  certainly  does 
not).  The  adoption  of  one  or  other  of  them  may  be  secured 
where  more  perfect  but  more  complicated  and  expensive  systems 
may  be  out  of  the  question. 

4.  The  Pneumatic  System  of  Liernur. — A  system  which 
seems  to  be  useful  in  larger  cities,  especially  where  the  topo- 
graphical conditions  are  such  as  to  render  necessary  mechanical 
aid  in  overcoming  obstacles  to  natural  drainage,  is  the  pneu- 
matic system  devised  by  Captain  Liemur,  of  Holland,  and 
generally  known  as  the  Liernur  system.  It  consists  of  a  set  of 
soil-pipes  running  from  the  water-closets  to  central  district 
reservoirs,  from  which  the  air  is  exhausted  at  stated  intervals. 
When  a  vacuum  is  created  in  the  reservoir  the  contents  of  the 
water-closets  and  soil-pipes  are  driven  forcibly  into  the  reservoir 
by  the  pressure  of  air.  The  district  reservoirs  are  connected  by 
a  separate  system  of  pipes  with  a  main  depot,  and  the  transfer 
of  the  faBcal  matter  from  the  former  to  the  latter  is  also  accom- 
plished with  the  aid  of  pneumatic  pressure.  The  complete 
system  of  Liernur  provides  that  at  the  main  depot  the  faecal 
matter  shall  be  treated  with  chemicals,  evaporated,  and  con- 
verted into  a  dry  fertilizer — poudrette.  It  appears  from  the 
published  reports  that  while  the  system  has  been  partially 
adopted  in  three  Dutch  cities,  in  only  one  of  them,  Dortrecht, 
has  the  machinery  for  manufacturing  poudrette  been  established. 
AVith  reference  to  this  Erismaim1  says:  "It  seems  never  to  have 

1  Yon  Pettenkofer  und  Ziemssen  :  Handbuch  tier  Hygiene.  II  Th.,  II  Abth.,  1  Hefte, 
p.  140. 


156  TEXT-BOOK   OF    HYGIENE. 

been  in  regular  working  order,  for  the  faecal  masses  are  mixed 
with  street-sweepings  and  ashes  into  a  compost-mass,  which 
causes  no  little  discomfort  in  the  neighborhood  by  the  offensive 
odors.  In  Amsterdam  the  faecal  matters,  which  frequently  do 
not  find  a  ready  sale,  are  partly  made  into  a  compost  with 
sweepings,  partly  used  to  fertilize  meadows,  or  simply  discharged 
into  the  water." 

As  to  the  practical  working  of  the  system  the  opinions 
differ  widely.  While  the  majority  of  sanitarians,  including 
Virchow,  von  Pettenkofer,  and  Mr.  Rawlinson,  object  to  it  as 
not  fulfilling  the  demands  of  hygiene,  the  system  has  also  been 
criticized  by  engineers  as  not  being  in  accordance  with  the  well- 
known  principles  of  their  science.1 

Two  other  plans  for  the  removal  of  faecal  matter  by  pneu- 
matic pressure  have  been  invented,  namely,  the  Shone  and  the 
Berlier  systems.  Neither  of  these  has  been  adopted  to  any 
considerable  extent.  Both  seem  to  the  author  to  fall  far  short 
even  of  the  merits  of  the  Liernur  system. 

5.  The  Water- Carriage  System  of  Seiverage. — Two  sys- 
tems of  removal  of  sewage  by  water-carriage  are  in  use  at  the 
present  time.  They  are  technically  known  as  the  "  combined  " 
and  the  "  separate  "  systems.  In  the  former,  which  is  the  sys- 
tem upon  which  the  most  of  the  sewers  in  this  country  are 
constructed,  all  excreta,  kitchen-slops,  waste-water  from  baths 
and  manufacturing  establishments,  as  well  as  storm-water,  are 
carried  off  in  the  same  conduits.  In  the  separate  system,  on 
the  other  hand,  the  removal  of  the  storm-water  is  provided  for, 
either  by  surface  or  under-ground  drains,  not  connected  with  the 
sewers  proper,  in  which  only  the  discharge  from  water-closets 
and  the  refuse-water  from  houses  and  factories  are  conveyed. 
In  the  separate  system  the  pipes  are  of  such  small  calibre  that 
a  constant  flow  of  their  contents  is  maintained,  preventing 

1  Papers  by  Maj.  C.  H.  Latrobe  and  Col.  Geo.  E.  Waring,  Jr.,  in  Fifth  Biennial  Report 
Md.  State  Board  of  Health.  See  also,  in  favor  of  system,  a  paper  by  Dr.  C.  W.  Chancellor,  in 
same  publication,  and  an  elaborate  description  by  the  same  author  in  Trans.  Med.  and  Chir. 
Faculty  of  Md.,  1883. 


REMOVAL   OF   SEWAGE.  157 

deposition  of  suspended  matters  and  diminishing  decomposition 
and  the  formation  of  sewer-gas. 

In  the  combined  system,  on  the  other  hand,  the  sewers 
must  be  made  large  enough  to  receive  the  maximum  rain-fall  of 
the  district.  This  requires  a  calibre  greatly  in  excess  of  the 
ordinary  needs  of  the  sewer,  and  furnishes  favorable  conditions 
for  the  formation  of  sewer-gas  and  the  development  of  minute 
vegetable  organisms.  The  ordinary  flow  in  a  sewer  of  large 
calibre  is  usually  so  sluggish  as  to  promote  the  deposition  of 
solid  matters  and  the  gradual  obstruction  of  the  sewer. 

It  is  the  opinion  of  the  most  advanced  sanitarians  that  the 
separate  system  fulfills  the  demands  of  a  rational  system  of 
sewerage  better  than  any  other  at  present  in  use.  The  objec- 
tions to  the  combined  system  are  so  many  and  so  great  that  it 
does  not  seem  advisable  for  sanitary  authorities  to  recommend 
the  construction  of  sewers  on  this  principle  in  the  future. 

The  separate  system  of  sewerage,  indorsed  as  it  is  by  high 
engineering  and  sanitary  authorities,  and  by  a  satisfactory,  prac- 
tical test  of  twelve  years  in  the  city  of  Memphis  and  of  nine  years 
in  the  town  of  Keene,  N.  H.,  seems  to  the  author  to  possess 
merits  above  any  other  plan  for  the  removal  of  excreta  and 
house-wastes.  The  following  description  is  from  a  paper  by 
Col.  George  E.  Waring,  Jr.:  UA  perfect  system  of  sanitary 
sewerage  would  be  something  like  the  following:  No  sewer 
should  be  used  of  a  smaller  diameter  than  6  inches  (15  centi- 
metres) :  a,  because  it  will  not  be  safe  to  adopt  a  smaller  size 
than  4-inch  (10  centimetres)  for  house-drains,  and  the  sewer 
must  be  large  enough  to  surely  remove  whatever  may  be  de- 
livered by  these;  b,  because  a  smaller  pipe  than  6-inch  would 
be  less  readily  ventilated  than  is  desirable ;  c,  and  because  it  is 
not  necessary  to  adopt  a  smaller  radius  than  3  inches  (5  centi- 
metres) to  secure  a  cleansing  of  the  channel  by  reasonably 
copious  flushing. 

"No  sewer  should  be  more  than  6  inches  (15  centimetres) 
hi  diameter,  until  it  and  its  branches  have  accumulated  a 


158  TEXT-BOOK   OF   HYGIENE. 

sufficient  flow  at  the  hour  of  greatest  use  to  fill  this  size  half  full, 
because  the  use  of  a  larger  size  would  be  wasteful,  and  because 
when  a  sufficient  ventilating  capacity  is  secured,  as  it  is  in  the 
use  of  a  6-inch  pipe,  the  ventilation  becomes  less  complete  as 
the  size  increases,  leaving  a  larger  volume  of  contained  air  to 
be  moved  by  the  friction  of  the  current,  or  by  extraneous  in- 
fluences, or  to  be  acted  upon  by  changes  of  temperature  and 
of  volume  of  flow  within  the  sewer. 

"The  size  should  be  increased  gradually,  and  only  so 
rapidly  as  is  made  necessary  by  the  filling  of  the  sewer  half 
full  at  the  hour  of  greatest  flow. 

"  Every  point  of  the  sewer  should,  by  the  use  of  gaskets 
or  otherwise,  be  protected  against  the  least  intrusion  of  cement, 
which,  in  spite  of  the  greatest  care,  creates  a  roughness  that  is 
liable  to  accumulate  obstructions. 

"  The  upper  end  of  each  branch  sewer  should  be  provided 
with  a  Field's  flush-tank  of  sufficient  capacity  to  secure  the 
thorough  daily  cleansing  of  so  much  of  the  conduit  as  from  its 
limited  flow  is  liable  to  deposit  solid  matters  by  the  way. 

"  There  should  be  sufficient  man-holes,  covered  by  open 
gratings,  to  admit  air  for  ventilation.  If  the  directions  already 
given  are  adhered  to,  man-holes  will  not  be  necessary  for  cleans- 
ing. The  use  of  the  flush-tank  will  be  a  safeguard  against 
deposit.  With  the  system  of  ventilation  about  to  be  described, 
it  will  suffice  to  place  the  man-holes  at  intervals  of  not  less  than 
1000  feet  (305  metres). 

"  For  the  complete  ventilation  of  the  sewers  it  should  be  made 
compulsory  for  every  householder  to  make  his  connection  without 
a  trap,  and  to  continue  his  soil-pipe  above  the  roof  of  his  house. 
That  is,  every  house  connection  should  furnish  an  uninter- 
rupted ventilation-channel  4  inches  (10  centimetres)  in  diameter 
throughout  its  entire  length.  This  is  directly  the  reverse  of  the 
system  of  connection  that  should  be  adopted  in  the  case  of 
storm-water  and  street-wash  sewers.  These  are  foul,  and  the 
volume  of  their  contained  air  is  too  great  to  be  thoroughly  ven- 


REMOVAL   OF   SEWAGE.  159 

tilated  by  such  appliances.  Their  atmosphere  contains  too  much 
of  the  impure  gases  to  make  it  prudent  to  discharge  it  through 
house-drains  and  soil-pipes.  With  the  system  of  small  pipes 
now  described,  the  flushing  would  be  so  constant  and  complete 
and  the  amount  of  ventilation  furnished,  as  compared  to  volume 
of  air  to  be  changed,  would  be  so  great,  that  what  is  popularly 
known  as  '  sewer-gas '  would  never  exist  in  any  part  of  the 
public  drains.  Even  the  gases  produced  in  the  traps  and  pipes 
of  the  house  itself  would  be  amply  rectified,  diluted,  and  removed 
by  the  constant  movement  of  air  through  the  latter. 

"All  house  connections  with  the  sewers  should  be  through 
inlets  entering  in  the  direction  of  the  flow,  and  these  inlets 
should  be  funnel-shaped  so  that  their  flow  may  be  delivered  at 
the  bottom  of  the  sewer,  and  so  that  they  may  withdraw  the  air 
from  its  crown;  that  is,  the  vertical  diameter  of  the  inlet  at  its 
point  of  junction  should  be  the  same  as  the  diameter  of  the 
sewer. 

"  All  changes  of  direction  should  be  on  gradual  curves,  and, 
as  a  matter  of  course,  the  fall  from  the  head  of  each  branch  to 
the  outlet  should  be  continuous.  Reduction  of  grade  within 
this  limit,  if  considerable,  should  always  be  gradual. 

"So  far  as  circumstances  will  allow,  the  drains  should  be 
brought  together,  and  they  should  finally  discharge  through  one 
or  a  few  main  outlets. 

"  The  outlet,  if  water-locked,  should  have  ample  means  for 
the  admission  of  fresh  air.  If  open,  the  mouth  should  be  pro- 
tected against  the  direct  action  of  the  wind. 

"  It  will  be  seen  that  the  system  of  sewerage  here  described 
is  radically  different  from  the  usual  practice.  It  is  cleaner,  is 
much  more  completely  ventilated,  and  is  more  exactly  suited  to 
the  work  to  be  performed.  It  obviates  the  filthy  accumulation 
of  street-manure  in  catch-basins  and  sewers,  and.it  discharges  all 
that  is  delivered  to  it  at  the  point  of  ultimate  outlet  outside  the 
town  before  decomposition  can  even  begin.  If  the  discharge  is 
of  domestic  sewage  only,  its  solid  matter  will  be  consumed  by 


160  TEXT-BOOK  OF   HYGIENE. 

fishes  if  it  is  delivered  into  a  water-course,  and  its  dissolved 
material  will  be  taken  up  by  aquatic  vegetation. 

"  The  limited  quantity .  and  the  uniform  volume  of  the 
sewage,  together  with  the  absence  of  dilution  by  rain-fall,  will 
make  its  disposal  by  agricultural  or  chemical  processes  easy  and 
reliable. 

"The  cost  of  construction,  as  compared  with  that  of  the 
most  restricted  storm-water  sewers,  will  be  so  small  as  to  bring 
the  improvement  within  the  reach  of  the  smaller  communities. 

"In  other  words,  while  the  system  is  the  best  for  large 
cities,  it  is  the  only  one  that  can  be  afforded  in  the  case  of 
small  towns. 

"  Circumstances  are  occasionally  such  as  to  require  extensive 
engineering  works  for  the  removal  of  storm-water  through  very 
deep  channels.  Ordinarily,  the  removal  of  storm- water  is  a  very 
simple  matter,  if  we  will  accept  the  fact  that  it  is  best  carried, 
so  far  as  possible,  by  surface  gutters,  or,  in  certain  cases,  by 
special  conduits,  placed  near  the  surface. 

"  It  is  often  necessary,  in  addition  to  the  removal  of  house- 
waste,  to  provide  for  the  drainage  of  the  subsoil.  This  should 
not  be  effected  by  open  joints  in  the  sewers;  because  the  same 
opening  that  admits  soil-water  may,  in  dry  seasons  and  porous 
soils,  permit  the  escape  of  sewage  matters  into  the  ground, 
which  is  always  objectionable. 

"  Soil- water  drains  may  be  laid  in  the  same  trench  with  the 
sewers,  but  preferably,  unless  they  have  an  independent  outlet, 
on  a  shelf  at  a  higher  level.  When  they  discharge  into  the 
sewer  they  should  always  deliver  into  its  upper  part,  or  into  a 
man-hole  at  a  point  above  the  flow-line  of  the  sewage."1 

The  establishment  of  a  system  of  sewerage  presupposes  a 
constant  and  abundant  supply  of  water  to  keep  all  closets  clean 
and  all  house-drains  and  street-sewers  well  flushed.  Where  this 
cannot  be  obtained,  sewers  would  be  likely  to  prove  greater 
evils  than  benefits.  In  such  cases  one  of  the  methods  of  removal 

1  The  Sewering  and  Drainage  of  Cities,  Waring,  Public  Health,  vol.  v,  p.  35. 


REMOVAL   OF    SEWAGE.  161 

of  excreta  before  mentioned,  either  the  pail-  or  earth-  closet 
system,  should  be  adopted. 

The  final  disposal  of  sewage  is  a  problem  that  depends  for 
its  solution  partly  upon  the  agricultural  needs  of  the  country 
around  the  city  to  be  sewered,  partly  upon  the  proximity  of 
large  bodies  of  water  or  running  streams.  When  the  city  is 
situated  upon  or  near  large  and  swiftly-flowing  streams,  the 
sewage  may  be  emptied  directly  into  the  stream  without  seriously 
impairing  the  purity  of  the  latter,  although  the  principle  of  thus 
disposing  of  sewage  is  wrong.  Dilution,  deposition,  and  oxida- 
tion will  soon  remove  all  appreciable  traces  of  the  sewage  of 
even  the  largest  cities.  Where,  on  the  other  hand,  the  stream 
is  inadequate  in  size  to  carry  off  the  sewage,  or  where,  as  in  the 
Seine  and  Thames,  the  current  is  sluggish,  some  other  method 
of  final  disposal  must  be  adopted. 

In  many  cities  of  Great  Britain  and  the  continent  of  Europe 
the  disposal  of  the  sewage  by  irrigation  of  cultivated  land  has 
been  practiced  for  a  number  of  years.  The  reports  upon  the 
working  of  the  system  are  generally  favorable,  although  some 
sanitarians  express  doubts  of  the  efficiency  of  the  system.  In 
using  sewage  for  the  irrigation  of  land,  two  objects  are  secured : 
first,  the  fertilization  of  the  land  by  the  manurial  constituents 
of  the  sewage,  and,  second,  the  purification  of  the  liquid  portion 
by  filtration  through  the  soil.  The  organic  matters  which  have 
been  held  back  by  the  soil  undergo  rapid  oxidation  in  the  presence 
of  air  and  the  bacteria  of  decay,  and  are  converted  into  plant- 
food,  or  into  harmless  compounds.  Sewage  irrigation,  as  prac- 
ticed in  Europe,  must  make  provision  for  the  disposal  of  a  very 
large  proportion  of  water  in  the  sewage  (street-wash,  storm- 
water),  which  requires  much  larger  areas  of  land  than  would  be 
needed  if  only  sewage  material  proper  (water-closet  and  kitchen- 
waste)  was  to  be  thus  disposed  of.  In  this  country  a  practical 
experiment  has  recently  been. made  at  Pullman,  Illinois,  delivering 
only  the  sewage  materials  above  mentioned  upon  the  irrigation 
area.  The  success  of  the  experiment  is  said  to  be  satisfactory. 


11 


162  TEXT-BOOK   OF   HYGIENE. 

All  land  used  for  sewage  irrigation  should  be  drained  with 
drain- tile  at  a  depth  of  3  to  6  feet  (1  to  2  metres)  below  the 
surface,  in  order  to  promote  a  rapid  carrying  off  of  the  watery 
portion  of  the  sewage,  purified  by  filtration  through  the  soil.  A 
sandy  loam  is  the  best  soil  for  irrigation.  Clay  is  not  sufficiently 
permeable  to  air  and  water,  while  pure  sand  allows  the  sewage 
to  pass  through  too  readily,  before  the  organic  matters  in  it 
have  been  sufficiently  oxidized.  It  has  been  shown  that  the 
roots  of  plants  assist  largely  in  the  oxidation  of  organic  matter. 

The  entire  process  of  collecting  and  finally  disposing  of 
sewage  matters,  from  the  moment  they  are  received  in  the  house- 
receptacles  until  discharged  into  the  swiftly-flowing  stream  or  on 
the  sewage  farm,  should  be  void  of  offense  to  the  senses  of  sight 
or  smell.  With  a  proper  construction  and  management  of 
sewerage  works,  on  the  hues  indicated  in  this  chapter,  it  is 
believed  these  results  can  be  attained. 

During  the  past  five  or  six  years  a  number  of  experi- 
ments have  been  made  in  this  country  with  various  processes  for 
the  disposal  of  excreta  and  garbage  by  cremation.  In  a  general 
way  the  principle  may  be  pronounced  a  success,  although  its 
proper  application  in  practice  is  still  under  discussion. 

[The  following  works  give  fuller  details  upon  the  matters 
treated  in  the  two  foregoing  chapters: — 

Erismann,  Entfernung  der  Abfallstoffe.  Hdbch.  d.  Hygiene,  etc., 
II  Tli.,  I  Abth.,  1  Hlfte.— C.  F.  Folsoin,  Seventh  Report  Mass.  State 
Board  of  Health,  1876,  p.  276. — Soyka,  Stadte-reinigung,  in  Realency- 
clopsedie  d.  ges.  Heilk.,Bd.  xiii,  p.  14  et  seq. — Pettenkofer,  The  Sanitary 
Relations  of  the  Soil,  in  Pop.  Sci.  Monthly,  vol.  xx,  pp.  332,  468. — Cor- 
tield  and  Parkes,  The  Treatment  and  Utilization  of  Sewage,  1887. — Re- 
ports of  the  Committee  on  Destruction  of  Garbage  and  Refuse,  Public 
Health,  vols.  xiv  and  xv. — Soyka,  Der  Boden  in  Hdbch.  d.  Hygiene, 
I  Thl.,  2  Abth.,  3  Heft.— W.  Santd  Crimp,  Sewage-Disposal  Works.— 
Waring,  Modern  Methods  of  Sewage  Disposal.] 


QUESTIONS   TO   CHAPTER  V. 

REMOVAL  OF  SEWAGE. 

Why  must  arrangements  be  made  in  all  large  communities  for  the 
removal  of  sewage  ?  To  what  do  the  organic  constituents  of  sewage 
give  rise,  and  what  is  the  effect  upon  health  of  the  continued  inhalation 
of  these  products  ?  How  else  may  the  impregnation  of  the  soil  with 
sewage  endanger  health  ?  What,  then,  is  the  object  of  any  system  of 
sewage  removal  ?  What  will  likely  govern  the  choice  and  adoption  of  a 
sewage-removal  system  by  an}-  community  ? 

What  different  systems  are  in  use  at  the  present  time?  Which  of 
these  is  the  worst  and  most  unsanitary  ?  In  case  the  privy  system  is  to 
be  considered,  what  conditions  should  be  insisted  upon  ?  How  may  a 
privy  be  ventilated  ?  Why  should  a  privy  not  be  located  in  a  cellar  nor 
too  near  the  house?  What  substances  may  be  used  to  deodorize  the 
contents  of  privy-vaults,  and  how  ?  Are  deodorizers  always  disinfect- 
ants, and  is  the  danger  necessarily  removed  when  the  odor  is  destroyed? 
How  often  should  privy-vaults  be  emptied?  How  may  this  be  done 
without  offense  to  the  senses  ?  What  are  the  grave  objections  to  the 
midden  or  shallow-pit  system,  and  to  digging  the  vault  or  cess-pool  to 
the  level  of  the  ground-water  ? 

What  is  meant  by  the  Rochdale  or  pail-closet  system  ?  What  are 
some  of  its  advantages  ?  What  can  be  said  of  its  efficacy  for  large  com- 
munities and  for  the  economy  of  administration  ?  What  is  an  earth- 
closet,  and  upon  what  does  its  efficacy  depend  ?  What  are  some  of  its 
advantages  ? 

Describe  the  pneumatic  system  of  Liernur.  Has  it  apparently  been 
satisfactory  in  its  workings  ?  What  other  systems  have  employed  the 
pneumatic  principle,  and  with  what  success  ? 

What  do  we  mean  by  the  water-carriage  system  of  sewerage  ?  What 
two  systems  are  embraced  under  this  head  ?  What  is  the  distinction 
between  the  two  ?  Which  is  in  most  common  use  ?  What  must  be  the 
size  of  the  sewers  in  the  combined  system,  and  what  are  the  consequent 
objections  ?  Why  does  the  separate  system  seem  the  better  ?  Describe 
the  latter  in  detail.  What  governs  the  size  of  the  drains  in  the  separate 
system  ?  How  is  this  system  kept  clean  and  free  from  obstructions  ? 
How  is  it  to  be  ventilated  ?  How  does  it  differ  in  this  respect  from  the 
combined  system  ?  What  are  some  of  the  especial  points  to  be  observed 

(163) 


164  QUESTIONS   TO    CHAPTER   V. 

in  the  construction  ?  What  may  be  said  as  to  cost  of  construction  and 
as  to  the  ultimate  disposal  of  the  sewage  ?  Why  should  sewers  not  be 
empktyed  to  drain  the  subsoil?  How  may  this  be  done? 

What  does  the  establishment  of  a  sewerage  system  presuppose?  If 
plenty  of  water  cannot  be  had,  what  system  of  sewage  removal  should 
be  adopted  ? 

In  what  way  may  we  finally  dispose  of  the  sewage  ?  What  are  the 
objections  to  discharging  it  into  running  streams  ?  How  will  it  be  finally 
disposed  of  in  such  a  stream?  What  is  meant  by  the  irrigation,  the 
sub-irrigation,  and  the  filtration  methods  ?  What  becomes  of  the  organic 
matter  of  the  sewage  in  each  case?  What  of  the  sewage  water  ?  What 
sort  of  soil  is  needed  for  the  irrigation  method?  What  can  be  said  of 
the  disposal  of  sewage  and  garbage  by  cremation  ? 


CHAPTER  VI. 

CONSTRUCTION  OF  HABITATIONS. 

THE  importance  of  observing  the  principles  of  hygiene  in 
the  construction  of  habitations  for  human  beings  is  not  suffi- 
ciently appreciated  by  the  public.  Architects  and  builders  them- 
selves have  not  kept  pace  with  the  sanitarian  in  the  study  of  the 
conditions  necessary  to  be  observed  in  building  a  dwelling-house 
which  shall  answer  the  requirements  of  sanitary  science. 

In  an  investigation  conducted  by  Dr.  Villerme1  it  was  found 
that  in  France,  from  1821  to  1827,  of  the  inhabitants  of  arron- 
dissements  containing  7  per  cent,  of  badly-constructed  dwellings, 
1  person  out  of  every  72  died ;  of  inhabitants  of  arrondissements 
containing  22  per  cent,  of  badly-constructed  dwellings,  1  out  of 
65  died ;  while  of  the  inhabitants  of  arrondissements  containing 
38  per  cent,  of  badly-constructed  dwellings,  1  out  of  every  45  died. 

Inseparable  from  the  question  of  the  defective  construction 
of  dwellings  is  that  of  overcrowding  in  cities,  because  the  most 
crowded  portions  of  a  city  are  at  the  same  time  those  in  which 
the  construction  of  dwellings  is  most  defective  from  a  hygienic 
stand-point.  The  following  tables  show  the  relations  of  the 
death-rate  to  density  of  population  in  various  large  cities  of 
Europe,  and  also  the  relations  between  overcrowding  in  dwell- 
ings and  the  mortality  from  contagious  diseases : — 

TABLE  XVII. 

RELATION    OF   DEATH-RATE    TO    DENSITY    OF    POPULATION. 


CITY. 

Mean  Number  of  Inhab- 
itants to  each  House. 

Average  Death-rate  per 
1000  Inhabitants. 

8 

24 

32 

25 

35 

28 

52 

41 

55 

47 

1  Quoted  in  Realeucyclopaedia  d.  ges.  Heilk,  Bd.  ii,  71. 


(165) 


166  TEXT-BOOK   OF   HYGIENE. 

In  Glasgow,  the  death-rate  in  apartments  with  1.31  occu- 
pants is  21.7  per  1000,  while  in  apartments  with  2.05  occupants 
the  rate  is  28.6  per  1000. 

In  Buda-Pesth,  in  1872-73,  it  was  found  that  out  of  every  100 
deaths  from  all  causes  there  were,  from  contagious  diseases : — 

20  deaths  in  dwellings  with  1  to    2  persons  in  each  room. 

.)()       ..        -•         "  "     3  «     5        <<         "      "         " 

qo      ••       ••         «  ••     6  ••  10       ••         "     "        " 

79      "       "        "  "    over  10       "         "     "        " 

Dr.  Jose  A.  de  los  Rios  gives  the  following  statistics,  bear- 
ing upon  the  mortality  of  cholera,  in  relation  to  the  number  of 
persons  occupying  one  room  when  attacked  by  it : — 

Of  10,000  persons  attacked  by  cholera,  and  living  1  person 
to  the  room,  68  died. 

Of  10,000  persons  attacked  by  cholera,  from  1  to  2  to  the 
room,  131  died. 

Of  10,000  persons  attacked  by  cholera,  living  2  to  4  to  the 
room,  219  died. 

Of  10,000  persons  attacked  by  cholera,  living  4  or  more  to 
the  room,  327  died. 

These  figures  show  very  clearly  the  vital  importance  of  the 
application  of  sanitary  laws  in  the  construction  and  occupation 
of  dwellings. 

Another  curious  and  suggestive  point  is  presented  by  some 
statistical  researches  on  the  mortality  of  Berlin,  in  regard  to  the 
death-rate  among  persons  living  in  different  stories  of  houses.  It 
was  found,  for  example,  that  the  mortality  in  fourth-story  dwell- 
ings is  higher  than  in  the  lower  stories.  Even  basement  dwell- 
ings furnish  a  lower  death-rate.  Still-births,  especially,  occur 
in  a  larger  proportion  among  the  occupants  of  the  upper  stories 
of  houses.  This  may  be  explained  by  the  unfavorable  effects  of 
frequent  stair-climbing,  especially  in  pregnant  women. 

It  is  in  the  death-rate  among  young  children  that  the  effects 
of  overcrowding  and  unsanitary  construction  of  dwellings  are 
especially  manifest.  The  mortality  returns  from  all  the  large 


CONSTRUCTION    OF    HABITATIONS. 


167 


cities    of   the   world   give   mournful   evidences   of    this   every 
summer. 

The  researches  of  Dr.  H.  I.  Bowditch  upon  soil- wetness,  to 
which  reference  has  already  been  made  in  a  previous  chapter, 
show  conclusively  that  persons  living  in  houses  situated  upon 
or  near  land  habitually  or  excessively  wet,  are  especially  prone 
to  be  attacked  by  pulmonary  consumption.  Dr.  Buchanan1  has 
corroborated  the  truth  of  Dr.  Bowditch's  observations  by  show- 
ing, from  the  records  of  a  number  of  cities  and  towns  of  Great 
Britain,  that,  with  the  introduction  of  a  good  drainage  system, 
bringing  about  a  depression  and  uniformity  of  level  of  the 
ground-water,  the  mortality  from  consumption  and  other  dis- 
eases very  markedly  diminished.  The  following  table,  showing 
the  proportionate  amount  of  this  diminution,  is  abridged  from 

the  official  reports2 : — 

TABLE  XVIII. 

RESULTS   OF    SANITARY   WORK. 


NAME  OF  PLACE. 

Population 
m  1861. 

Average 
Mortality  per 
1000  before 
Construction 
of  .Works. 

Average 
Mortality 
per  1000 
since  Com- 
pletion of 
Works. 

Saving  of 
Life 
(percent.). 

Reduc- 
tion of 
Typhoid 
Fever 
Rate  (per 
cent.  )  . 

Reduc- 
tion in 
Rate  of 
Phthisis 
(percent.). 

Banbury 

10,238 

23.4 

20.5 

12* 

48 

41 

Cardiff  . 

32,954 

33.2 

22.6 

32 

40 

17 

Croydon 

30,229 

23.7 

18.6 

22 

63 

17 

Dover  '  . 

23,108 

22.0 

20.9 

7 

36 

20 

Ely    .     . 

7,847 

23.9 

20.5 

14 

56 

47 

Leicester 

68,056 

26.4 

25.2 

*i 

48 

32 

Macclesfield 

27,475 

29.8 

23.7 

20 

48 

31 

Merthyr 

52,778 

33.2 

26.2 

18 

60 

11 

Newport 

24,756 

31.8 

21.6 

32 

36 

32 

Rugby    . 

7,818 

19.1 

18.6 

2* 

10 

43 

Salisbury 

9,030 

27.5 

21.9 

20 

75 

49 

Warwick 

10,570 

22.7 

21.0 

7* 

52 

19 

The  following  points  must  be  taken  into  account  in  building 
a  house  in  accordance  with  sanitary  principles : — 

i. — SITE. 

The    building-site    should   be    protected    against    violent 
winds,  although  a  free  circulation  of  air  all  around  the  house 

1  Ninth  and  Tenth  Reports  of  the  medical  officer  to  the  Privy  Council. 
1  Sanitary  Engineering,  Baldwin  Latham,  p.  2.    Chicago,  1877. 


168  TEXT-BOOK    OF    HYGIENE. 

must  be  secured.  Close  proximity  to  cemeteries,  marshes,  and 
injurious  manufacturing  establishments  or  industries  must  be 
avoided  if  possible.  A  requisite  of  the  highest  importance  is 
the  ability  to  command  an  abundant  supply  of  pure  water  for 
drinking  and  other  purposes.  A  neglect  of  this  precaution  will 
be  sure  to  result  to  the  serious  inconvenience,  if  not  detriment, 
of  the  occupants  of  the  house. 

II. CHARACTER   OF   THE    SOIL. 

The  soil  should  be  porous  and  free  from  decomposing  ani- 
mal or  vegetable  remains,  or  excreta  of  man  or  animals.  It 
should  be  freely  permeable  to  air  and  water,  and  the  highest 
level  of  the  ground-water  should  never  approach  nearer  than 
3  metres  to  the  surface.  The  fluctuations  of  the  ground-water 
level  should  be  limited.  In  this  connection,  attention  is  again 
called  to  the  aphorism  of  Dr.  DeChaumont. l 

It  is  impossible  to  say  positively  that  any  kind  of  soil  is 
either  healthy  or  unhealthy,  merely  from  a  knowledge  of  its 
geological  characters.  The  accidental  modifying  conditions 
above  referred  to,  viz.,  organic  impurities,  moisture,  the  level 
and  fluctuations  of  the  ground-water,  are  of  much  greater 
importance  than  mere  geological  formation.  The  late  Dr. 
Parkes,  however,  regarded  the  geological  structure  and  conforma- 
tion as  of  no  little  importance,  and  summarized  the  sanitary 
relations  of  soils,  variously  constituted,  as  follows2: — 

"1.  The  Granitic,  MetamorpJi fr.  < i,i< /  Trap  Rock*. — Sites 
on  these  formations  are  usually  healthy ;  the  slope  is^-reat,  water 
runs  off  readily;  the  air  is  comparatively  dry;  vegetation  is  not 
excessive;  marshes  and  malaria  are  comparatively  infrequent; 
and  few  impurities  pass  into  the  drinking-water. 

"When  these  rocks  have  been  weathered  and  disintegrated 
they  are  supposed  to  be  unhealthy.     Such  soil  is  absorbent  of 
water;  and  the  disintegrated  granite  of  Hong  Kong  is  said  to 
• 

1  Chapter  iv,  p.  130. 

'  Practical  Hygiene,  6th  ed.,  vol.  i,  p.  359. 


CHARACTER    OF    THE    SOIL.  169 

be  rapidly  permeated  by  a  fungus;  but  evidence  as  to  the  effect 
of  disintegrated  granite  or  trap  is  really  wanting. 

"In  Brazil  the  syenite  becomes  coated  with  a  dark  sub- 
stance and  looks  like  plumbago,  and  the  Indians  believe  this 
gives  rise  to  'calentura,'  or  fevers.  The  dark  granitoid,  or 
metamorphic  trap,  or  hornblendic  rocks  in  Mysore,  are  also  said 
to  cause  periodic  fevers;  and  iron  hornblende,  especially,  was 
affirmed  by  Dr.  Heyne,  of  Madras,  to  be  dangerous  in  this 
respect.  But  the  observations  of  Bichter  on  similar  rocks  in 
Saxony,  and  the  fact  that  stations  on  the  lower  spurs  of  the 
Himalayas  on  such  rocks  are  quite  healthy,  negative  Heyne's 
opinion. 

"  2.  The  Clay  Slate. — These  rocks  precisely  resemble  the 
granite  and  granitoid  formations  in  their  effect  on  health.  They 
have  usually  much  slope,  are  very  impermeable,  vegetation  is 
scanty,  and  nothing  is  added  to  air  or  drinking-water. 

"They  are  consequently  healthy.  Water,  however,  is 
often  scarce,  and  as  to  the  granite  districts,  there  are  swollen 
brooks  during  rain,  and  dry  water-courses  at  other  times  swelling 
rapidly  after  rains. 

"  3.  The  Limestone  and  Magnesian  Limestone  Roclcs. — 
These  so  far  resemble  the  former  that  there  is  a  good  deal  of 
slope  and  rapid  passing  off  of  water.  Marshes,  however,  are 
more  common,  and  may  exist  at  great  heights.  In  that  case, 
the  marsh  is  probably  fed  with  water  from  some  of  the  large 
cavities  which  in  the  course  of  ages  become  hollowed  out  in  the 
limestone  rocks  by  the  carbonic  acid  in  the  rain,  and  form 
reservoirs  of  water. 

"The  drinking-water  is  hard,  sparkling,  and  clear.  Of 
the  various  kinds  of  limestone,  the  hard  oolite  is  best  and 
magnesian  is  worst;  and  it  is  desirable  not  to  put  stations  on 
magnesian  limestone  if  it  can  be  avoided. 

"4.  The  Chalk. — The  chalk,  when  mixed  with  clay,  and 
permeable,  forms  a  very  healthy  soil.  The  air  is  pure,  and 
the  Water,  though  charged  with  calcium  carbonate,  is  clear, 


170  TEXT-BOOK   OF   HYGIENE. 

sparkling,  and  pleasant.  Goitre  is  not  nearly  so  common,  nor 
apparently  calculus,  as  in  the  limestone  districts. 

"If  the  chalk  be  marly,  it  becomes  impermeable,  and  is 
then  often  damp  and  cold.  The  lower  parts  of  the  chalk,  which 
are  underlaid  by  gault  clay,  and  which  also  receive  the  drainage 
of  the  parts  above,  are  often  very  malarious;  and  in  America 
some  of  the  most  marshy  districts  are  in  the  chalk. 

"5.  The  /Sandstones. — The  permeable  sandstones  are  very 
healthy ;  both  soil  and  air  are  dry ;  the  drinking-water  is,  how- 
ever, sometimes  impure.  If  the  sand  be  mixed  with  much  clay, 
or  if  clay  underlies  a  shallow  sand-rock,  the  site  is  sometimes 
damp. 

"  The  hard  millstone-grit  formations  are  very  healthy,  and 
their  conditions  resemble  those  of  granite. 

"  6.  Gravels  of  any  depth  are  always  healthy,  except  when 
they  are  much  below  the  general  surface,  and  water  rises  through 
them.  Gravel  hillocks  are  the  healthiest  of  all  sites,  and  the 
water,  which  often  flows  out  in  springs  near  the  base,  being 
held  up  by  the  underlying  clay,  is  very  pure. 

"  7.  Sands. — There  are  both  healthy  and  unhealthy  sands. 
The  healthy  are  the  pure  sands,  which  contain  no  organic 
matter,  and  are  of  considerable  depth.  The  air  is  pure,  and  so 
is  often  the  drinking-water.  Sometimes  the  drinking-water  con- 
tains enough  iron  to  become  hard,  and  even  chalybeate.  The 
unhealthy  sands  are  those  which,  like  the  subsoil  of  the  Landes, 
in  southwest  France,  are  composed  of  silicious  particles  (and 
some  iron)  held  together  by  a  vegetable  sediment. 

"  In  other  cases  sand  is  unhealthy  from  underlying  clay  or 
laterite  near  the  surface,  or  from  being  so  placed  that  water 
rises  through  its  permeable  soil  from  higher  levels.  Water  may 
then  be  found  within  3  or  4  feet  of  the  surface ;  and  in  this  case 
the  sand  is  unhealthy  and  often  malarious.  Impurities  are 
retained  in  it  and  effluvia  traverse  it. 

"In  a  third  class  of  cases  the  sands  are  unhealthy  because 
they  contain  soluble  mineral  matter.  Many  sands  (as,  for  ex- 


CHARACTER   OF   THE    SOIL.  171 

ample,  in  the  Punjab)  contain  magnesium  carbonate  and  lime- 
salts,  as  well  as  salts  of  the  alkalies.  The  drinking-water  may 
thus  contain  large  quantities  of  sodium  chloride,  sodium  carbon- 
ate, and  even  lime  and  magnesian  salts  and  iron.  Without 
examination  of  the  water  it  is  impossible  to  detect  these  points. 

"8.  Clay,  Dense  Marls,  and  Alluvial  Soils  Generally. — 
These  are  always  regarded  with  suspicion.  Water  neither  runs 
off  nor  runs  through ;  the  air  is  moist ;  marshes  are  common ; 
the  composition  of  the  water  varies,  but  it  is  often  impure  with 
lime  and  soda  salts.  In  alluvial  soils  there  are  often  alterations 
of  thin  strata  of  sand,  and  sandy,  impermeable  clay.  Much 
vegetable  matter  is  often  mixed  with  this,  and  air  and  water  are 
both  impure. 

"The  deltas  of  great  rivers  present  these  alluvial  characters 
in  the  highest  degree,  and  should  not  be  chosen  for  sites.  If 
they  must  be  taken,  only  the  most  thorough  drainage  can  make 
them  healthy.  It  is  astonishing,  however,  what  good  can  be 
effected  by  the  drainage  of  even  a  small  area,  quite  insufficient 
to  affect  the  general  atmosphere  of  the  place ;  this  shows  that  it 
is  the  local  dampness  and  the  effluvia  which  are  the  most 
hurtful. 

"9.  Cultivated  Soils. — Well-cultivated  soils  are  often 
healthy ;  nor  at  present  has  it  been  proved  that  the  use  of  manure 
is  hurtful.  Irrigated  lands,  and  especially  rice-fields,  which  not 
only  give  a  great  surface  for  evaporation,  but  also  send  up 
organic  matter  into  the  air,  are  hurtful.  In  Northern  Italy, 
where  there  is  a  very  perfect  system  of  irrigation,  the  rice- 
grounds  are  ordered  to  be  kept  14  kilometres  (8.7  miles)  from 
the  chief  cities,  9  kilometres  (5.6  miles)  from  the  lesser  cities  and 
the  forts,  and  1  kilometre  (1094  yards)  from  the  smaller  towns. 
In  the  rice  countries  of  India  [and  America]  this  point  should 
not  be  overlooked." 

Where  a  wet,  impermeable,  or  impure  soil  must,  of  neces- 
sity, be  chosen  as  a  building-site,  it  should  be  thoroughly 
drained.  The  minimum  depth  at  which  drains  are  laid  should 


172  TEXT-BOOK   OF   HYGIENE. 

be  not  less  than  1^  metres  below  the  floor  of  the  cellar  or  base- 
ment. Such  a  soil  should  be  covered  with  a  thick,  impervious 
layer  of  asphaltum  or  similar  cement  under  the  house,  in  order 
to  prevent  the  aspiration  of  the  polluted  ground-air  into  the 
building. 

It  is  a  frequent  custom  in  cities  to  fill  in  irregularities  of 
the  building-site  with  street-sweepings  and  garbage,  which 
always  contain  large  quantities  of  decomposing  organic  matters. 
This  is  a  gross  violation  of  the  plainest  principles  of  hygiene. 
It  is  almost  equally  reprehensible  to  use  such  decaying  or 
putrefying  organic  material  for  the  purpose  of  grading  streets 
or  sidewalks  in  cities  and  towns.1  « It  should  be  the  constant 
endeavor  of  all  sanitary  authorities  to  prevent  pollution  of  the 
soil  as  much  as  possible  in  villages,  towns,  and  cities. 

Where  houses  are  built  on  the  declivity  of  a  hill,  the  upper 
wall  should  not  be  built  directly  against  the  ground,  as  it  would 
tend  to  keep  the  wall  damp.  A  vacant  space  should  be  loft 
between  the  wall  and  the  ground  to  permit  free  access  of  air 
and  light. 

In  addition  to,  or  in  default  of,  drainage,  the  drying  of  soil 
can  be  promoted  by  rapidly-growing  plants,  which  absorb  water 
from  the  soil  and  give  it  out  to  the  air.  The  sunflower  and  the 
eucalyptus  tree  are  the  most  available  for  this  purpose. 

III. THE   MATERIAL   OF   WHICH    THE   HOUSE   IS   BUILT. 

The  nature  of  the  most  appropriate  building  material  de- 
pends upon  so  many  collateral  circumstances  that  definite  rules 
cannot  be  laid  down.  As  a  general  rule,  moderately  hard 
burned  brick  is  the  most  serviceable  and  available  material.  It 
is  easily  permeable  by  the  air,  and  so  permits  natural  ventila- 
tion through  the  walls,  unless  this  is  prevented  by  other  means. 

1  During  the  very  fatal  epidemic  of  yellow  fever  in  New  Orleans,  in  187S,  it  was  ascer- 
tained that  a  contractor  for  street-work  used  the  garbage  and  street-scrapings  to  grade  the  bed 
of  the  streets.  Kven  though  in  this  case  it  may  not  have  intensified  the  epidemic  in  these 
localities,  the  practice  is  so  contrary  to  tin-  simplest  sanitary  laws  that  it  should  nowhere  be 
tolerated.  The  author  is  aware,  however,  that  the  "  made-ground  "  of  nearly  every  city  in  this 
country  is  composed  largely  of  just  such  material.  All  sanitarians  should  protest  against  a 
continuance  of  this  pernicious  practice. 


MATERIAL    OF    WHICH    THE    HOUSE    IS   BUILT.  173 

It  does  not  absorb  and  hold  water  readily ;  hence,  damp  walls 
are  infrequent  if  brick  is  used.  It  is  probably,  of  all  building 
material,  the  most  durable.  On  account  of  its  porosity  a  brick 
wall  is  a  poor  conductor  of  heat.  It  therefore  prevents  the 
rapid  cooling  of  a  room  in  cold  weather,  and  likewise  retards 
the  heating  of  the  inside  air  from  without  in  summer.  Another 
very  great  advantage  is  its  resistance  to  a  very  high  degree  of 
heat,  brick  being  probably  more  nearly  fire-proof  than  any 
other  building  material. 

In  hot  climates  light  wooden  buildings  are  advantageous, 
because  they  cool  oif  very  rapidly  after  the  sun  has  disappeared. 
On  account  of  the  numerous  joints  and  fissures  in  a  frame 
building,  natural  ventilation  goes  on  very  readily  and  to  a  con- 
siderable extent. 

Next  to  brick,  granite,  marble,  and  sandstone  are  the  most 
serviceable  building  materials.  Very  porous  sandstone  is,  how- 
ever, not  very  durable  in  cold  climates,  as  the  stone  absorbs  large 
quantities  of  water,  which,  in  .consequence  of  the  expansion 
accompanying  the  act  of  freezing,  produces  a  gradual  but 
progressive  disintegration. 

The  application  of  paint  to  the  walls,  either  within  or  with- 
out, almost  completely  checks  the  transpiration  of  air  through 
the  walls,  thus  limiting  natural  ventilation.  Calcimining,  on 
the  other  hand,  offers  very  little  obstruction  to  the  passage  of 
air.  Wall-paper  is  about  midway  between  paint  and  lime- 
coating  in  its  obstructive  effect  on  atmospheric  transpiration. 

Newly-built  houses  should  not  be  occupied  until  the  walls 
have  become  dry.  Moisture  in  the  walls  is  probably  a  not 
infrequent  source  of  ill  health;  it  offers  favorable  conditions  for 
the  development  of  fungi  (possibly  of  disease-germs),  and,  by 
filling  up  the  pores  of  the  material  of  which  the  walls  are 
composed,  prevents  the  free  transpiration  of  air  through 
them. 

Moisture  of  the  walls  is  sometimes  due  to  the  ascent  of 
the  water  from  the  soil  by  capillary  attraction.  This  can  be 


174  TEXT-BOOK   OF   HYGIENE. 

prevented  by  interposing  an  impervious  layer  of  slate  in  the 
foundation-wall. 

Where  the  moisture  is  due  to  the  rain  beating  against  the 
outside  walls,  and  thus  saturating  them  if  composed  of  porous 
materials,  a  thorough  external  coating  of  impervious  paint  will 
prove  a  good  remedy. 

IV. INTERIOR    ARRANGEMENTS. 

A.  Size  of  Rooms,  and  Ventilating  and  Heating  Arrange- 
ments.— The  rooms  in  dwelling-houses  should  never  be  under 
2!  metres  in  height  from  floor  to  ceiling.  In  sleeping-rooms 
the  initial  air-space  should  never  be  less  than  35  cubic  metres 
for  adults,  and  25  cubic  metres  for  children  under  10  years  of 
age.  Provision  must  be  made  for  changing  this  air  sufficiently 
often  to  maintain  it  at  its  standard  of  purity;  i.e.,  less  than  7 
parts  of  carbon  dioxide  per  10,000.  The  details  for  accomplish- 
ing this  will  vary  with  the  architects'  designs,  the  material  of 
which  the  house  is  constructed,  the  climate,  and  the  season. 
The  principles  laid  down  in  the  section  on  ventilation  (Chapter 
I)  should  be  adhered  to.  In  cold  weather  the  air  should  be 
warmed,  either  before  its  entrance  into  the  room  or  afterward,  by 
stove  or  fire-place.  Galton's  jacketed  stove,  or  fire-place,  seems 
to  answer  this  purpose  admirably.  The  details  of  the  heating 
apparatus  must  be  left  to  individual  taste,  or  other  circum- 
stances. It  may  be  noted,  however,  in  passing,  that  the  pre- 
vailing method  of  heating  houses  by  means  of  hot  air  is  objec- 
tionable for  various  reasons ;  partly,  because  the  air  is  usually  too 
dry  to  be  comfortable  to  the  respiratory  organs ;  partly,  because 
organic  matter  is  frequently  present  in  large  proportions,  and 
gives  the  air  an  offensive  odor  when  the  degree  of  heat  is  high 
enough  to  scorch  the  organic  matter.  Both  these  objections 
are,  however,  removable ;  the  first,  by  keeping  a  vessel  of  water 
constantly  in  the  furnace,  so  that  the  hot  air  can  take  up  a 
sufficient  proportion  of  vapor  in  passing  through,  and,  the  second, 
by  having  the  furnace  made  large  enough  so  that  the  tempera- 


INTERIOR    ARRANGEMENTS. 


175 


ture  need  never  be  raised  to  a  very  high  degree.  Heating  by 
hot  water  or  steam  is  preferable  to  the  hot-air  furnace.  Both 
of  these  methods  are,  however,  more  expensive. 

Where  special  ventilating  arrangements  are  necessary,  air- 


a,  a,  sash:  6,  6,  window-jambs  ;  c,  c,  window- 
sill.  This  cut  represents  the  view  from 
within  the  Hury  Ventilator,  in  operation. 
It  is  broken  away  at  one  end  to  show  the 
sash  raised  above  the  outer  holes  to  admit 
the  air. 


FIG.  7. 

a,  a,  sash.  This  cut  represents  the  view  from 
without  the  Bury  Ventilator,  in  operation. 
The  sash  is  hrok'en  away  to  show  the  ven- 
tilator behind,  with  the  fresh  air  passing 
in. 


inlets  may  be  inserted  at  appropriate  points  in  the  walls  of  the 
room,  facing  toward  the  air.  A  simple  arrangement  is  that  known 
as  the  Bury  Ventilator,  shown  in  Figs.  6  and  7.  It  consists 
of  a  wooden  block  interposed  between  the  bottom  of  the  lower 


176 


TEXT-BOOK   OF   HYGIENE. 


window-sash  and  the  window-frame.  The  air  passes  into  the  room 
through  the  openings  in  the  block,  as  shown  in  the  illustration. 
The  separation  of  the  upper  and  lower  sashes,  when  the  ventilator 


t-      **T 

\  i 


is  in  place,  also  adds  to  the  efficiency  of  the  ventilation,  as  the 
air  passes  in  through  the  space  so  formed. 

A  cheaper  ventilator  can  be  made  by  simply  tacking  a  strip 


INTERIOR    ARRANGEMENTS.  177 

of  canvas,  binders'  board,  or  manilla  paper,  20  to  25  centimetres 
wide,  across  the  lower  portion  of  the  window-frame,  and  then 
raising  the  sash  10  to  15  centimetres.  The  air  will  pass  in 
under  the  lower  and  between  the  lower  and  upper  sashes  and 
pass  upward  toward  the  ceiling  and  then  gradually  diffuse  itself 
through  the  room.  In  summer  a  counter-opening  may  be  ob- 
tained for  the  escape  of  foul  air  by  lowering  the  upper  sash, 
while  in  winter  a  stove  or  fire-place  will  furnish  a  good  exit. 

Fig.  8  shows  the  probable  course  of  the  air-currents  in  a 
room  ventilated  by  means  of  a  fresh-air  inlet  near  the  ceiling 
and  an  open  fire-place.  A  is  the  inlet ;  C  the  fire-place ;  G  the 
floor ;  Ft  ceiling ;  E  E,  flues. 

B.  Internal   Wall-Coating. — A  point  of  considerable  im- 
portance   in  the  outfitting  of  dwelling-houses  is  the  material 
used  for  coating  or  decorating  the  inside  of  the  walls.     Green 
paint  and  green-colored  wall-papers  should  be  rejected.     The 
reason  for  avoiding  this  color  is  the  following :   Bright-green 
pigments  and  dyes  are  largely  composed  of  some  compound  of 
arsenic,  which  becomes  detached  from  the  wall  or  paper  when 
dry.  and,  being  inhaled,  produces  a  train  of  symptoms  which 
have  been  recognized  as  chronic  arsenical  poisoning.     Many 
cases  have  been  reported  in  which  serious  and  even  fatal  poison- 
ing has  been  produced  in  this  way.1     It  would  be  advisable, 
therefore,  to  discard  all  bright-green  tints  in  paints  and  orna- 
mental paper-hangings. 

C.  Lighting . — Provision  should  be  made  in  all  dwelling- 
houses  for  an  abundant  supply  of  sunlight.    Every  room  should 
have  at  least  one  window  opening  directly  to  the  sun.     It  is  not 
sufficient  to  give  an  ample  window-space,  which   should  be  in 
the  proportion  of  one  to  five  or  six  of  floor-space,  but  the  im- 
mediate surroundings  of  the  house  must  be  taken  into  account. 
Thus,  close  proximity  of  other  buildings,  or  of  trees,  may  pre- 
vent sufficient  light  entering  a  room,  although   the  window- 

1  Arsenic  in  Certain  Green  Colors,  F.  W.  Draper.  Third  Annual  Report  Mass.  State 
Board  of  Health,  1872,  pp.  18-57. 

12 


178  TEXT-BOOK   OF   HYGIENE. 

space   may   be    in    excess   of    that   required    under    ordinary 
circumstances. 

Some  form  of  artificial  light  will  also  be  needed  in  all 
dwellings.  Certain  dangers  are  necessary  accompaniments  of 
all  available  methods  of  artificial  illumination.  The  danger 
from  fire  is,  of  course,  the  most  serious.  This  danger  is  prob- 
ably least  where  candles  are  used,  and  greatest  where  the  more 
volatile  oils  (kerosene,  gasolene)  are  employed.  The  use  of 
candles  results  in  pollution  of  the  air  by  carbon  dioxide  and 
other  products  of  combustion  to  a  greater  degree  than  when 
other  illuminating  agents  are  used ;  they  also  give  out  a  larger 
amount  of  heat  in  proportion  to  their  power  of  illumination. 
Kerosene  gives  a  good  light  when  burned  in  a  proper  lamp,  and 
is  cheap,  but  the  dangers  from  explosion  and  fire  are  consider- 
able. The  danger  from  explosion  can  be  greatly  reduced  by 
always  keeping  the  lamp  filled  nearly  to  the  top,  and  never  fill- 
ing it  near  a  light  or  fire.  The  danger  of  explosion  is  increased 
when  the  chimney  of  the  lamp  is  broken,  as  then  the  tempera- 
ture of  the  metal  collar,  by  which  the  burner  is  fastened  to  the 
lamp,  is  rapidly  raised1  and  the  oil  vaporized.  If,  at  the  same 
time,  the  lamp  is  only  partially  filled  with  oil,  the  space  above  it 
is  occupied  by  an  explosive  mixture  of  air  and  the  vapor  of  the 
oil.  If  this  is  heated  to  a  sufficient  degree  an  explosion  will 
take  place.2 

The  use  of  coal-gas  is  probably  attended  by  less  danger 
than  the  lighter  oils,  but  by  more  than  other  means  of  illumina- 
tion. In  addition  to  the  dangers  from  fire  and  explosions,  which 
are  inevitable  accompaniments  of  defects  in  the  fixtures,  the 
escaping  gas  is  itself  exceedingly  poisonous  from  the  large 
amount  of  carbon  monoxide  it  contains.  It  is,  in  fact,  a  very 
frequent  occurrence  in  large  cities  that  persons  are  killed  by  the 
inhalation  of  gas  which  has  escaped  from  the  fixtures  or  was 

1  H.  B.  Baker,  in  Report  Mich.  State  Hoard  of  Health,  1876,  p.  48. 

«  See  an  instructive  paper  by  Prof.  K.  C.  Kedzie,  in  Report  Mich.  State  Board  of  Health 
for  1877,  p.  71  et  seq. 


INTERIOR   ARRANGEMENTS.  179 

allowed  to  escape  from  the  burner  through  ignorance.  That 
variety  of  illuminating  gas  known  as  "water-gas"  is  more  dan- 
gerous to  inhale  than  coal-gas  owing  to  the  larger  proportion  of 
carbon  monoxide  contained  in  it.  The  "  natural  gas  "  used  as  a 
fuel  and  illuminant  in  some  places  in  the  United  States  is  espe- 
cially dangerous  from  the  total  absence  of  odor.  The  gas  may 
escape  in  large  quantity  and  fail  to  give  notice  of  its  presence 
except  by  an  explosion,  if  ignited,  or  by  producing  asphyxia  in 
those  who  incautiously  venture  into  the  air  permeated  by  it. 

The  electric  light  (Edison's  incandescent  system)  is  prob- 
ably open  to  less  objection  on  the  score  of  danger  than  any 
other  of  the  illuminating  systems  mentioned.  There  is  no  trust- 
worthy evidence  that  the  electric  light  has  any  unfavorable  in- 
fluence on  the  vision,  although  Regnault  supposed  it  would  have 
a  bad  effect  upon  the  ocular  humors  on  account  of  the  large 
proportion  of  the  violet  and  ultra-violet  rays  it  contained.  In 
order  to  remove  this  objection  Bouchardat  advised  the  wearing 
of  yellow  glasses  by  those  compelled  to  use  this  light  for  close 
work.  The  advantages  of  the  incandescent  light,  besides  the 
brilliant  white  light  it  gives,  are  that  it  is  steady  and  does  not 
produce  any  heat,  nor  does  it  pollute  the  air  with  carbon  dioxide 
and  other  products  of  combustion.  Professor  von  Pettenkofer 
has  recently  shown  experimentally  that  the  pollution  of  the  air 
by  the  products  of  combustion  is  very  much  greater  when  gas 
is  used  than  where  the  electric  light  is  employed.  The  electric 
arc-lights  are  extremely  dangerous  on  account  of  the  high  poten- 
tial maintained  in  the  wires,  and  the  difficulty  of  thoroughly 
insulating  the  latter.  Many  deaths  have  occurred  from  this 
source,  and,  unless  a  method  is  discovered  and  adopted  by 
which  the  voltage  of  the  arc-light  current  can  be  greatly  dimin- 
ished without  decreasing  the  efficiency  of  the  light,  this  method 
( of  lighting  must  soon  be  given  up  in  cities,  owing  to  its  danger, 
not  only  to  those  directly  brought  in  contact  with  the  conductors, 
but  to  others  who  may  indirectly  get  in  the  way  of  the  errant 
current. 


180  TEXT-BOOK   OF    HYGIENE. 

In  writing,  sewing,  reading,  or  other  work  requiring  a  con- 
stant use  of  accurate  vision,  the  light,  whether  natural  or  artifi- 
cial, should  fall  upon  the  object  from  above  and  on  the  left  side. 
Hence,  windows  and  burners  should  be  at  least  at  the  height 
of  the  shoulder  and  to  the  left  of  the  person  using  the  light. 

Increased  ventilation  facilities  must  be  provided  where  arti- 
ficial light  (except  the  electric  light)  is  used  to  any  extent.  It 
has  been  calculated  that  for  every  lighted  gas-burner  12  to  15 
cubic  metres  of  fresh  air  per  hour  must  be  furnished  in  addition 
to  the  amount  ordinarily  required  in  order  to  maintain  the  air 
of  the  room  at  the  standard  of  purity. 

V. WATER-SUPPLY. 

The  water-supply  of  a  dwelling-house  should  be  plentiful  for 
all  requirements,  and  its  distribution  should  be  so  arranged  that 
the  supply  for  every  room  is  easily  accessible.  Where  prac- 
ticable, water-taps  should  be  placed  on  every  floor,  both  for 
convenience  and  for  greater  safety  in  case  of  fire.  It  is  also  a 
result  of  observation  that  personal  habits  of  cleanliness  increase 
in  a  direct  ratio  with  the  ease  of  obtaining  the  cleansing  agent. 
The  inmates  of  a  house  where  water  is  obtainable  with  little 
exertion  are  much  more  likely  to  be  cleanly  in  habits  than 
where  the  water-supply  is  deficient  or  not  readily  procured. 

VI. HOUSE-DRAINAGE. 

Provision  must  be  made  for  the  rapid  and  thorough  removal 
of  waste-water  and  excrementitious  substances  from  the  house. 
This  is  most  easily  and  completely  accomplished  by  well-con- 
structed water-closets  and  sinks.  Water-closets  should,  however, 
not  be  tolerated  in  any  room  occupied  as  a  living-  or  bed-  room. 
It  would  doubtless  be  very  much  more  in  accordance  with  sani- 
tary requirements  to  have  all  permanent  water-fixtures,  water- 
closets,  and  bathing  arrangements  placed  in  an  annex  to  the 
dwelling  proper.  In  this  way  the  most  serious  danger  from 
water-closets  and  all  arrangements  having  a  connection  with  a 


HOUSE-DRAINAGE.  181 

cess-pool  or  common  sewer — permeation  of  the  house  by  sewer- 
air — could  be  avoided. 

Water-closets,  however,  presuppose  an  abundant  supply  of 
water.  Unless  this  can  be  obtained  and  rendered  available  for 
flushing  the  closets,  soil-pipe,  and  house-drain,  the  dry-earth  or 
pail  system  should  be  adopted.  Privies  should  not  be  coun- 
tenanced. Experience  in  several  large  cities  of  Europe  has 
demonstrated1  that  the  pail  system  can  be  adopted  with  advan- 
tage and  satisfactorily  managed  even  in  large  communities. 

As  house-drainage  may  be  considered  the  first  and  most . 
important  link  in  a  good  sewerage  system,  a  brief  description 
will  be  here  given  of  the  details  of  the  drainage  arrangements 
of  a  dwelling-house.  The  rapid  and  complete  removal  of  all 
fa3cal  and  urinary  discharges,  lavatory-  and  bath-  wastes,  and 
kitchen-slops  must  be  provided  for.  For  these  purposes  are 
needed,  first,  water-closets  and  urinals,  wash-basins  and  bath- 
tubs, and  kitchen-  or  slop-  sinks ;  second,  a  perpendicular  pipe, 
with  which  the  foregoing  are  connected,  termed  the  soil-pipe; 
and,  third,  a  horizontal  pipe,  or  house-drain,  connecting  with  the 
common  cess-pool  or  sewer. 

A.  Water-  Closets  — There  are  five  classes  of  water-closets 
in  general  use.  They  are  the  pan-,  valve-,  plunger-,  hopper-,  and 
washout-  closets. 

Pan-closets  are  those  found  in  most  old  houses  containing 
water-closet  fixtures.  Just  under  the  bowl  of  the  closet  is  a 
shallow  pan  containing  a  little  water,  in  which  the  dejections 
are  received.  On  raising  the  handle  of  the  closet,  the  pan  is 
tilted  and  the  water  at  the  same  time  is  turned  on,  which  washes 
out  the  excrement  and  sends  it  into  or  through  the  trap  between 
the  closet  and  the  soil-pipe.  It  will  be  readily  understood  that 
the  space  required  for  the  movement  of  the  pan — the  "  container," 
as  it  is  termed — is  rarely  thoroughly  cleansed  by  the  passage  of 
water  through  it.  Feecal  matter,  paper,  etc.,  gradually  accumu- 
late in  the  corners  of  the  container,  and,  as  a  consequence,  pan- 

1  See  Chapter  v,  p.  139. 


182  TEXT-BOOK   OF   HYGIENE. 

closets  are  always,  after  a  brief  period  of  use,  foul.  There  are 
other  defects  in  the  construction  of  the  pan-closet  which  render 
it  untrustworthy,  but  the  one  especially  pointed  out — the  impos- 
sibility of  keeping  it  clean — is  enough  to  absolutely  condemn  its 
use,  from  a  sanitary  point  of  view.  It  is  decidedly  the  worst 
form  of  closet  that  can  be  used. 

Valve-closets  are  merely  modifications  of  the  pan-closet. 
The  bottom  of  the  bowl  is  closed  by  a  flat  valve,  which  is  held 
in  its  place  by  a  weight,  By  moving  a  lever  the  valve  is  tinned 
down,  allowing  the  excreta  to  drop  into  the  container.  The  only 
differences  between  the  pan-  and  valve-  closets  are  that  in  the 
latter  a  flat  valve  is  substituted  for  the  pan  of  the  former,  and 
that  this  allows  the  container  to  be  made  smaller.  Otherwise, 
there  are  no  advantages  in  the  valve-closet.  Considered  from  a 
sanitary  stand-point,  the  valve-closet  is  no  worse  than  the  pan- 
clpset,  and  but  very  little,  if  any,  better. 

The  third  variety,  or  plunger-closet,  has  several  marked 
advantages  over  the  two  just  described.  The  characteristic 
feature  of  the  closets  of  this  class  is  that  the  outlet,  which  is 
generally  on  one  side  of  the  bowl,  is  closed  by  a  plunger.  This 
bowl  is  always  from  one-third  to  one-half  full  of  water,  into  which 
the  excreta  fall.  On  raising  the  plunger,  the  entire  contents  of 
the  bowl  are  rapidly  swept  out  of  the  apparatus  into  the  soil- 
pipe,  the  bowl  thoroughly  washed  out  by  a  sudden  discharge  of 
water,  and,  on  closing  the  outlet  with  the  plunger,  the  bowl  is 
again  partly  filled  witli  water.  An  overflow  attachment  prevents 
accumulation  of  too  large  a  quantity  of  water  in  the  bowl.  This 
overflow,  however,  sometimes  becomes  very  foul  and  objection- 
able. The  Jennings,  Demarest,  and  Hygeia  are  types  of  this 
class.  The  principal  objection  is  that  the  plunger  sometimes 
fails  to  properly  close  the  outlet,  allowing  the  water  to  drain  out 
of  the  bowl,  and  thus  destroying  one  of  its  principal  advantages. 
The  mechanism  is  also  somewhat  complicated  and  likely  to  get 
out  of  order. 

The  hopper-closet  consists  of  a  deep  earthenware  or  enameled 


HOUSE-DRAINAGE. 


183 


iron  bowl,  with  a  water-seal  trap  directly  underneath.  The 
excreta  are  received  directly  into  the  proximal  end  of  the  trap, 
and  when  the  water  is  turned  on  the  sides  of  the  bowl  are 
washed  clean  and  everything  in  the  bowl  and  trap  swept  directly 
into  the  soil-pipe.  There  is  no  complicated  mechanism  to  get 
out  of  order,  the  trap  is  always  in  sight,  and  the  entire  appa- 
ratus can  always  be  kept  clean  and  inoffensive,  as  there  are  no 
hidden  corners  or  angles  for  filth  to  lodge.  This  form  of  closet 
is,  all  things  considered,  one  of  the  best  for  general  use. 


FIG.  9.— THE  "DECECO"  CLOSET.    (New  Fonn.) 


The  "  wash-out  "  closets  are  of  various  shapes,  some  having 
the  trap  in  the  bowl  itself,  others  having  a  double  water-trap. 
They  are  generally  simple  in  construction,  and  not  likely  to  get 
out  of  order.  They  do  not  present  any  decided  advantages  over 
the  simple  hopper,  although  at  the  present  time  they  are  more 
used  than  any  other  form  of  closet.  Of  the  recent  improvements 
in  this  form  of  closet  may  be  mentioned  the  "A.  G.  M.,"1  shown 

1  Manufactured  by  the  Myers  Sanitary  Depot,  New  York. 


184 


TEXT-BOOK   OF    HYGIENE. 


A 


FIG.  10.— THE  "A.  G.  M."  CLOSET. 


HOUSE-DRAINAGE.  185 

in  view  with  cistern  in  Fig.  10,  and  in  section  in  Fig.  11,  and 
the  "  Dececo,"  Fig.  9,  invented  by  Col.  George  E.  Waring. 
In  the  latter  the  automatic  siphon  principle,  so  ingeniously  used 
by  Rogers  Field  in  the  construction  of  the  automatic  flush-tank, 
is  applied  to  the  scouring  of  a  water-closet.  Practical  experi- 
ence for  six  or  seven  years  has  demonstrated  the  great  usefulness 
of  this  closet.  If  the  delivery  of  water  from  the  flushing-cistern 
is  properly  regulated,  at  first  rapid  to  thoroughly  wash  out  the 


FIG.  11.— SECTIONAL  VIEW  OF  "A.  Q.  M."  CLOSET. 

closet  and  connections,  and  then  slow  to  re-establish  the  proper 
depth  of  seal  in  the  trap,  the  closet  should  be  thoroughly  satis- 
factory in  its  working. 

Water-closets  should  not  be  inclosed  in  wooden  casings,  as 
is  almost  universally  done.  Everything  connected  with  the 
closet,  soil-  and  drain-  pipes,  water-supply,  and  all  joints  and  fix- 
tures should  be  exposed  to  view  so  that  the  defects  can  be  imme- 
diately seen  and  easily  corrected.  By  laying  the  floor  and  back 
of  the  closet  in  tiles  or  cement,  such  an  arrangement  can  even 


186  TEXT-BOOK   OF   HYGIENE. 

be  made  ornamental,  as  suggested  by  Waring,1  who  says  that  a 
closet  "  made  of  white  earthenware,  and  standing  as  a  white 
vase  in  a  floor  of  white  tiles,  the  back  and  side  walls  being 
similarly  tiled,  there  being  no  mechanism  of  any  kind  under 
the  seat,  is  not  only  most  cleanly  and  attractive  in  appearance, 
but  entirely  open  to  inspection  and  ventilation.  The  seat  for  this 
closet  is  simply  a  well-finished  hard-wood  board,  resting  on  cleats 
a  little  higher  than  the  top  of  the  vase,  and  hinged  so  that  it  may 
be  conveniently  turned  up,  exposing  the  closet  for  thorough 
cleansing,  or  for  use  as  a  urinal  or  slop-hopper." 

Where  the  arrangement  here  described  is  adopted,  extra 
urinals  are  unnecessary  and  undesirable.  Where  they  are  used 
they  should  be  constantly  and  freely  flushed  with  water,  other- 
wise they  become  very  offensive.  The  floor  of  the  urinal  should 
be  either  of  tiling,  slate,  or  enameled  iron. 

B.  Water- Supply  for  Closets. — The  water-supply  for  flush- 
ing water-closets  should  not  be  taken  directly  from  the  common 
house-water  supply,  but  each  closet  should  have  an  independent 
cistern  large  enough  to  hold  a  sufficient  quantity  of  water  for  a 
thorough  flushing  (20  to  30  litres)  every  time  the  closet  is  used. 
The  objections  to  connecting  the  water-closet  directly  with  the 
common  house-supply  are,  that  there  is  often  too  little  head  of 
water  to  properly  flush  the  basin;  and,  secondly,  if  the  water 
be  drawn  from  a  fixture  in  the  lower  part  of  the  house,  while 
the  valve  of  a  water-closet  in  an  upper  floor  is  open  at  the  same 
time,  the  water  will  not  flow  in  the  latter  (unless  the  supply- 
pipe  is  very  large),  but  the  foul  air  from  the  closet  will  enter 
the  water-pipe,  and  may  thus  produce  dangerous  fouling  of  the 
drinking-water.  Hence,  separate  cisterns  for  each  water-closet 
should  always  be  insisted  upon. 

The  arrangement  of  these  cisterns  is  often  difficult  to  com- 

o 

prehend.  Fig.  12  shows  the  interior  arrangement  of  one  form. 
The  ball-shaped  float,  <r,  cuts  off  the  supply  when  the  tank  is 
full,  while  opening  the  valve,  &,  by  means  of  the  crank,  c,  dis- 

*  Sanitary  Condition  of  New  York  City,  Scribner's  Monthly,  vol.  xxii,  No  2,  June,  1881. 


HOUSE-DRAINAGE. 

charges  the  water.  The  rounded  annex,  d,  contains  enough 
water  to  partly  fill  the  closet-bowl  and  trap  after  the  contents 
have  been  washed  out  by  the  rapid  flush. 

C.  Traps. — Every  water-closet,  urinal,  wash-basin,  bath- 
tub, and  kitchen-sink  should  have  an  appropriate  trap  between 
the  fixture  and  the  soil-pipe.  The  trap  should  be  placed  as 
near  the  fixture  as  practicable,  as  pointed  out  above;  in  the 
best  forms  of  water-closet  the  bottom  of  the  closet  itself  forms 
part  of  the  trap. 


FIG.  12.— FLUSHING  CISTERN  FOR  WATER-CLOSETS. 


Traps  differ  in  shape  and  mechanism.  The  simplest  and 
usually  efficient  is  the  ordinary  S-trap  (Fig.  13).  This  trap  is 
of  uniform  diameter  throughout,  and  has  no  angles  for  the  lodg- 
ment of  filth.  A  free  flush  of  water  cleanses  it  perfectly,  and 
it  rarely  fails  to  furnish  a  sufficient  obstruction  to  the  passage 
of  sewer-air  from  the  soil-pipe,  unless  the  water  has  evaporated, 
or  been  forced  out  under  a  back-pressure  of  air  in  the  soil-pipe, 
or  been  siphoned  out,  and  thus  the  seal  broken. 


188  TEXT-BOOK   OF    HYGIENE. 

The  D-trap  and  bottle- trap  are  objectionable  on  account 
of  the  great  liability  of  becoming  fouled  by  filth  lodging  in  the 
corners,  while  in  the  mechanical  traps,  like  Bowers'  ball- valve 
trap,  CudelFs  trap,  and  others  of  this  class,  there  is  always 
danger  of  insufficient  seal  by  filth  adhering  to  the  valve,  and 
thus  preventing  its  exact  closure. 

Most  of  the  traps  now  furnished  by  the  dealers  in  plumbers' 
supplies  have  an  opening  in  the  highest  part  for  attaching  a 
vent-pipe.     It  has  been  found  that  the  seal  in  most  traps  can  be 
broken  by  siphonage,  if  the  pressure  of  air  on  the  distal  side 
(the  side  toward  the  soil-pipe)  of  the  trap  is  diminished,  or,  on 
the  other  hand,  by  increase  of  pressure  in  the  soil-pipe  the 
water  in  the  trap  may  be  forced  back  into  the  fixture,  and  thus 
sewer-air  enter  the  room.     By  providing  for  a 
free  entrance  and  exit  of  air  to  the  trap  this 
X**v       breaking  of  the  seal  can  be  prevented.     The 
/  /""^         ventilation  of  traps  is,  however,  an  evil,  as  it 
\^**^J  furnishes  an  additional  means  of  evaporation, 

and  when  the  fixture  is  not  in  frequent  (daily) 
use  the  seal  is  sooner  broken.     The  elaborate 

FIG.  13.— S-TRAJ>. 

extra  system  of  ventilation  of  traps,  so  generally 
insisted  upon  by  plumbers  and  sanitary  engineers,  is  unnecessary. 
If  the  soil-pipe  is  of  the  proper  size  and  height,  siphonage  of 
traps  will  not  be  likely  to  occur.  The  waste-pipe  connecting 
the  fixture  and  the  soil-pipe  should  be  as  short  as  possible;  in 
other  words,  all  water-closets,  urinals,  baths,  and  lavatories 
should  be  placed  as  near  the  soil-pipe  as  practicable,  in  order  to 
have  no  long  reaches  of  foul  waste-pipe  under  floors  or  in 
rooms. 

Dr.  E.  S.  McClellan  has  recently  invented  a  trap  which 
obviates  many  of  the  objections  urged  against  all  previous  de- 
vices, and  is  intended  to  meet  the  defects  of  the  S  and  other 
traps.  It  consists  of  a  body  containing  a  light,  inverted  cup,  with 
its  edges  resting  in  an  annular  groove  containing  mercury,  which 
forms  an  absolute  seal  against  the  escape  of  sewer-air.  When 


HOUSE-DRAINAGE. 


189 


a  slight  diminution  of  pressure  occurs  on  the  sewer  side  of  the 
cup,  the  greater  external  pressure  lifts  the  cup  out  of  the 
mercury  and  permits  a  free  inflow  of  air  until  the  wonted 
equilibrium  is  re-established,  when  the  cup  drops  back  into  the 
mercury  by  gravity,  and  effectually  closes  the  trap  against  any 
outflow.  With  this  trap  siphonage  of  the  seal  is  impossible. 
Fig.  14  shows  this  trap  with  the  cup  down,  and  Fig.  15  with 
the  cup  raised,  allowing  inflow  of  air. 

For  an  ordinary  wash-bowl  or  bath-waste  (which  should 


FIG.  14.— SECTIONAL  VIEW  OF  VENT,  WITH 
UUP  IN  NORMAL  POSITION. 


FIG.  15.— SECTIONAL  VIEW  OF  VENT.  WITH 
CUP  LIFTED  OUT  OF  THE  MERCUBY 
BY  THE  INFLOWING  CURRENT  OF  AIR 
INDICATED  BY  THE  ARROWS. 


always  be  trapped),  the  Connolly  globe- trap,  shown  in  Figs.  16 
and  1 7,  is  an  excellent  fixture.  It  is  impossible,  under  ordinary 
circumstances,  to  break  the  seal  by  siphonage. 

D.  The  Soil- Pipe. — The  vertical  pipe  connecting  the 
water-closets  and  other  fixtures  with  the  house-drain  is  called 
the  soil-pipe.  It  should  be  of  iron,  securely  jointed,  of  an  equal 
diameter  (usually  10  centimetres)  throughout,  and  extend  from 
the  house-drain  to  from  1|  to  2  metres  above  the  highest  point 
of  the  house.  The  connections  of  all  the  waste-pipes  from 
water-closets,  baths,  etc.,  should  be  at  an  acute  angle,  in  order 


190 


TEXT-BOOK   OF    HYGIENE. 


that  an  inflow  at  or  nearly  at  right  angles  may  not  produce  an 
obstruction  in  the  free  passage  of  air  up  and  down  the  soil-pipe. 
The  diameter  of  the  soil-pipe,  at  its  free  upper  end,  should  not 
be  narrowed;  in  fact,  according  to  Col.  Geo.  E.  Waring,  the 
up-draught  is  rendered  more  decided  if  the  upper  extremity  of 
the  soil-pipe  is  widened.1  The  internal  surface  of  the  pipe 
should  be  smooth,  and  especial  care  should  be  taken  to  prevent 
projections  inward  at  the  joints;  otherwise,  paper  and  other 


FIG.  16.— CONNOLLY  GLOBE-TRAP. 


FIG.  17:— GLOBE-TRAP  ATTACHED  TO  BASIN. 


matters  will  adhere  to  the  projections,  and  gradually  obstruct 
the  pipe. 

E.  The  House-Drain. — The  horizontal  or  slightly  inclined 
pipe  which  connects  the  lower  end  of  the  soil-pipe  with  the 
sewer  or  cess-pool,  the  point  of  final  discharge  from  the  house, 
should  be  of  the  same  diameter  and  material  as  the  soil-pipe. 
The  joints  should  be  made  with  equal  care,  and  the  pipe  should 
be  exposed  to  view  throughout  while  within  the  house-walls. 

»  Am.  Architect,  p.  124,  Sept  15, 1883. 


HOUSE-DRAINAGE.  191 

If  sunk  below  the  floor  of  the  cellar  it  should  be  laid  in  a 
covered  trench,  so  that  it  may  be  readily  inspected.  The  junc- 
tion between  the  vertical  and  horizontal  pipe  should'  not  be  at  a 
right  angle,  but  the  angle  should  be  rounded.  The  drain-pipe 
should  not  be  trapped.  This  is  contrary  to  the  advice  of  sanitary 
authorities  generally,  but  the  author  thinks  it  unadvisable  to  trap 
the  drain-pipe.  There  should  be  no  obstruction  to  the  outflow 
of  sewage  from  the  house,  and  a  trap  in  the  drain-pipe  is  of  no 
avail  against  the  passage  of  sewer-air  from  the  sewer  or  cess- 
pool into  the  soil-pipe,  if  the  pressure  of  the  air  in  the  former 
is  increased.  Furthermore,  if  the  passage  of  air  backward  and 
forward  between  the  sewer  and  the  external  air  at  a  sufficient 
height  (above  the  roofs  of  houses,  for  example)  is  free  and 
unobstructed,  the  sewers  (or  the  cess-pool,  as  the  case  may  be) 
will  be  better  ventilated  than  if  an  obstruction  to  such  free 
circulation,  in  the  form  of  a  trap,  be  placed  in  the  drain-pipe. 

.  Nearly  all  sanitary  authorities  direct  that  an  opening  for 
the  admission  of  fresh  air — "fresh-air  inlet" — should  be  made 
in  the  drain-pipe,  before  its  connection  with  the  sewer  or  cess- 
pool. This  is  done  with  the  view  of  having  a  constant  current 
of  fresh  air  entering  near  the  base  of  the  soil-pipe  and  passing 
upward  through  it.  Theoretically  the  current  ought  always  to 
pass  in  this  direction.  Practically,  however,  the  current  is 
found,  at  times,  to  pass  the  other  way,  and  the  foul  air  from  the 
soil-pipe  may  be  discharged  into  the  air  near  the  ground,  where 
it  would  be  much  more  likely  to  do  harm  than  when  discharged 
high  up  in  the  air  beyond  the  possibility  of  being  breathed. 

OFFICIAL    SUPERVISION    OF   THE    SANITARY   ARRANGEMENTS   OF 

DWELLINGS. 

In  most  cities  and  towns  the  municipal  authorities  have 
provided  for  an  official  inspection  of  buildings,  to  prevent  neglect 
of  precautions  against  fire  and  other  manifest  dangers  to  life. 
It  is  only  very  recently,  however,  that  the  authorities  of  some 
of  the  larger  cities  in  this  country  have  enacted  laws  to  prevent 


192  TEXT-BOOK   OF   HYGIENE. 

improper  construction  of  house-drainage  works.  Although  none 
of  these  laws  or  ordinances  cover  the  subject  completely,  yet 
their  proper  enforcement  must  result  in  great  advantage. 

Within  the  past  few  years,  following  the  example  of  Edin- 
burgh, volunteer  associations  have  been  organized  in  various 
cities  of  this  country',  with  the  object  of  securing  constant  expert 
inspection  and  supervision  of  the  drainage  arrangements  of 
dwellings  and  other  necessary  sanitary  improvements. 

The  good  results  accomplished  by  the  Newport  Sanitary 
Protection  Society,  the  New  Orleans  Auxiliary  Sanitary  Associa- 
tion, and  other  similar  bodies  attest  the  usefulness  of  such 
organizations. 

[The  following  works  are  recommended  to  the  student 
who  desires  a  fuller  knowledge  on  the  subjects  treated  in  this 
chapter : — 

W.  H.  Corfield,  Dwelling-Houses,  Their  Sanitary  Construction  and 
Arrangements,  N.  Y.,  1880. — Win.  Paul  Gerhard,  House-Drainage  and 
Sanitary  Plumbing,  Fourth  Report  State  Board  of  Health  of  R.  I., 
1881. — Eliot  C.  Clarke,  Common  Defects  in  House-Drains,  Tenth  Annual 
Report  Mass.  State  Board  of  Health,  1879.] 


QUESTIONS   TO   CHAPTER   VI. 
CONSTRUCTION  OP  HABITATIONS. 

Why  should  the  principles  of  hygiene  he  observed  in  the  construc- 
tion of  dwellings  ?  What  relation  is  there  between  badly-constructed 
and  overcrowded  dwellings  in  cities?  Between  overcrowded  dwellings 
and  the  death-rate,  either  general  or  from  contagious  diseases  ?  What 
class  of  persons  are  especially  atfected  by  overcrowding  and  unsanitary 
conditions  of  their  dwellings  ? 

What  points  should  be  taken  into  consideration  in  building  a  house? 
What  things  are  to  be  sought  and  what  avoided  in  selecting  a  site  ?  On 
what  kind  of  soil  should  the  house  be  built  ?  How  far  should  the  ground- 
water  be  below  the  surface,  even  at  its  highest?  What  must  be  known 
about  a  soil  to  determine  whether  it  is  sanitarily  suitable  for  building 
purposes?  What  is  the  usual  judgment  concerning  sites  on  granite, 
ti-ap,  or  metamorphic  rocks  ?  What  if  they  have  been  disintegrated  ? 
What  regarding  those  on  the  clay  slate  ?  Limestone  and  magnesian 
limestone?  Chalk?  Sandstone?  Gravel?  Sands?  Clays  and  alluvial 
soils?  Cultivated  lands?  Which  of  the  above  is  probably  the  best,  on 
general  principles,  for  the  site  for  a  dwelling  ?  Where  a  site  is  wet  or  the 
soil  is  impure,  what  must  be  done  ?  What  is  the  minimum  depth  at  which 
drains  for  the  soil-water  should  be  laid  ?  How  else  may  the  drying  of  the 
soil  be  promoted?  How  should  a  cellar  or  basement  over  an  impure  soil 
be  paved?  What  precaution  should  be  observed  in  building  a  house 
against  a  hill  ? 

What  are  some  of  the  materials  of  which  the  walls  of  a  house  may 
be  built  ?  What  are  the  advantages  of  good  brick  ?  Why  should  very 
porous  sandstone  not  be  used  for  building  purposes  in  cold  climates? 
What  is  the  effect  of  paint  upon  house-walls  ?  Has  calcimining  or  white- 
washing the  same  effect?  Has  wall-paper?  How  soon  should  newly -built 
houses  be  occupied  ?  To  what  are  moist  walls  sometimes  due,  and  how 
may  they  be  obviated  ? 

What  should  be  the  minimum  height  of  rooms  in  dwelling-houses? 
How  much  air-space  should  there  always  be  in  sleeping-rooms  for  adults 
and  children  ?  What  is  the  standard  of  purity  of  the  air  that  should  be 
maintained  constantly  ?  What  are  the  objections  to  heating  by  hot-air 
furnaces,  and  how  may  these  objections  be  avoided  ?  How  may  a  room 
be  ventilated  without  expensive  apparatus  ? 

What  colors  should  be  avoided  in  wall-paper  and  paints  for  inside 
work,  and  whj-  ?  What  should  be  the  proportion  of  window-space  to 
floor-space,  and  what  other  points'  should  be  observed  in  the  day-lighting 
of  rooms  ?  What  are  the  forms  of  artificial  light  used  for  household 

13  (193) 


194  QUESTIONS   TO   CHAPTER   VI. 

illumination,  and  what  are  the  dangers  accompanying  each  ?  What  are 
some  of  the  especial  advantages  of  the  incandescent  electric  light? 
From  what  direction  should  the  light  come  for  writing,  reading,  etc.  ? 
Why  must  there  be  increased  ventilation  where  artificial  lights  (except 
incandescent  electric)  are  used  ?  How  much  fresh  air  per  hour  is  needed 
to  properly  dilute  the  impurities  produced  by  burning  illuminating  gas  ? 

What  points  are  to  be  observed  regarding  the  water-supply  of  a 
dwelling  ?  Why  should  it  be  both  abundant  and  convenient  ? 

How  are  waste-waters  and  excrementitious  matters  most  readily 
removed  from  a  house  ?  Where  would  it  be  best  to  have  all  fixtures, 
etc.,  of  a  house-drainage  system  located,  if  possible?  What  do  water- 
closets,  etc.,  presuppose?  If  this  cannot  be  had,  what  system  should  be 
adopted  instead  ?  For  what  must  a  proper  house-drainage  system  pro- 
vide ?  What  are  the  component  parts  of  such  a  system  ? 

Where  should  water-closets  never  be  located  ?  What  five  classes  of 
water-closets  are  there?  Which  of  these  are  most  objectionable,  and 
why?  Describe  briefly  the  construction  of  a  pan-  and  a  valve-  closet. 
In  what  way  is  a  plunger-closet  better  than  a  pan-  or  valve-  closet  ? 
Wherein  is  it  sanitarily  imperfect?  Why  is  the  hopper-closet  one  of  the 
best?  What  two  kinds  of  hopper-closet  are  there?  What  can  be  said 
of  the  wash-out  closets?  What  is  the  principle  of  siphon  closets?  Why 
should  water-closets  and  other  fixtures  not  be  inclosed  in  wooden  casings  ? 
How  may  the  surroundings  of  such  closets  and  fixtures  be  further  im- 
proved ?  Why  should  the  water-supply  for  closets  not  be  taken  directly 
from  the  house-supply?  How  much  should  the  flushing  cistern  hold? 

What  are  traps  ?  Where  should  they  be  located  ?  How  many 
should  there  be  in  any  system  of  house-drainage  ?  What  is  the  simplest 
form  of  trap  ?  What  are  its  advantages  ?  Upon  what  does  the  value  of 
a  trap  depend  ?  What  is  to  be  avoided  in  the  selection  of  a  trap  ?  What 
is  meant  by  siphouage  ?  How  can  this  be  prevented  ?  To  what  part  of 
the  trap  is  the  vent-pipe  to  be  attached  ?  Where  should  the  other  end 
of  the  vent-pipe  open  ?  How  else  may  the  seal  of  a  trap  be  broken  ? 
What  is  the  principle  of  McClellan's  anti-siphon  trap? 

How  long  should  the  waste-pipe  connecting  the  fixtures  with  the 
soil-pipes  be  ?  What  is  the  soil-pipe  ?  Of  what  dimensions  should  it 
be?  Where  should  its  upper  extremity  end?  What  other  precautions 
should  be  observed  in  regard  to  the  soil-pipe? 

What  is  the  house-drain  ?  What  care  must  be  observed  in  the  laying 
of  it  ?  What  can  you  say  regarding  a  trap  between  the  house-drain  and 
sewer?  If  a  trap  is  thus  located,  what  else  must  there  be  between  the 
trap  and  the  house.  :uid  why?  What  can  be  said  regarding  the  official 
supervision  of  sanitary  arrangements  in  dwellings  ? 


CHAPTER  VII. 

CONSTRUCTION  OF   HOSPITALS. 

SITE. 

IF  the  choice  of  a  site  for  the  habitations  of  healthy  per- 
sons is  a  matter  of  vital  importance,  as  was  pointed  out  in  the 
last  chapter,  it  needs  no  argument  to  impress  upon  the  reader 
the  actual  necessity  of  choosing  a  site  with  wholesome  surround- 
ings for  a  habitation  for  the  sick.  In  selecting  a  site  for  a  hos- 
pital, therefore,  it  is  of  prime  importance  to  avoid  a  location 
where  unsanitary  influences  prevail. 

While  a  hospital  should  always  be  easily  accessible,  it  is 
not  desirable  that  it  should  be  in  a  noisy  or  crowded  part  of  a 
city.  Where  a  hospital  is  primarily  designed  for  the  reception 
of  accident  or  "  emergency  "  cases,  it  is,  of  course,  necessary  to 
have  it  near  to  where  accidents  are  likely  to  occur.  In  a  city 
this  will  probably  be  in  the  most  crowded  and  noisy  part. 

The  direction  of  the  prevailing  winds  from  the  city  should 
be  avoided  in  selecting  a  site  for  a  hospital. 

Free  admission  of  sunlight  and  air  must  be  secured  to  all 
parts  of  the 'hospital.  An  elevated  location  is  therefore  desir- 
able, although  exposure  to  violent  winds  must,  if  possible,  be 
avoided. 

The  soil  upon  which  a  hospital  is  built  should  be  clean, 
easily  drained,  with  a  deep  ground-water  level,  not  liable  to 
sudden  oscillations.  The  neighborhood  of  a  marshy  or  known 
malarious  region  should  be  avoided. 

THE   BUILDINGS, 

The  building  area  must  be  large  enough  to  permit  the 
construction  of  buildings  in  accordance  with  the  modern  recog- 
nized principles  of  hospital  construction.  Overcrowding  is  not 

(195) 


196  TEXT-BOOK   OF   HYGIENE. 

permissible,  either  of  the  grounds  by  buildings  or  of  the  build- 
ings by  patients. 

Having  determined  the  number  of  patients  for  whom  pro- 
vision is  to  be  made  and  the  character  of  the  diseases  to  be 
treated,  an  estimate  must  be  made  of  the  area  necessary  for  a 
hospital.  Taking  into  account  all  the  buildings  needed,  the 
area  required  will  be — for  two  or  more  storied  buildings — not 
less  than  30  square  metres  per  bed.  If  one-story  buildings 
are  to  be  erected  more  space  will  be  required,  and  if  infectious 
diseases  are  to  be  treated  in  the  hospital  the  above  space-allowance 
must  be  doubled  or  trebled.  In  the  new  Johns  Hopkins  Hos- 
pital, in  Baltimore,  the  area  occupied  by  the  buildings  is  56,000 
square  metres,  and  provision  is  to  be  made  for  300  patients. 
This,  covering,  of  course,  the  area  occupied  by  the  administra- 
tion building,  nurses'  home,  kitchen,  dispensary,  operating  and 
autopsy  theatre,  laundry,  etc.,  gives  an  area  of  187  square  metres 
per  bed.  The  actual  allowance  of  floor  space  per  bed  is  11^ 
square  metres ;  for  patients  with  infectious  diseases  the  space- 
allowance  is  nearly  treble,  being  29  square  metres. 

Within  recent  years  the  principles  of  hospital  construction 
have  undergone  considerable  modification.  While  formerly 
a  large  hospital  consisted  usually  of  one  large,  two  or  more 
storied  building,  in  which  all  the  various  departments  were 
comprised  under  one  roof,  the  aim  has  recently  been  to  scatter 
the  wards  as  much  as  practicable  consistent  with  reasonable  ease 
of  supervision  and  administration.  Under  the  former  plan,  with 
large  wards  connected  by  common  corridors  and  stairways,  ease 
of  administration  was  primarily  secured;  in  the  latter,  the 
most  important  object  of  a  hospital,  "  a  place  for  the  sick  to  get 
well  in,"  is  more  nearly  attained.  While  many  hospitals  are 
still  being  constructed  on  the  old  plan,  of  a  single  block  of 
several  stories  in  height,  nearly  all  sanitary  authorities  are 
agreed  that  the  plan  of  separate  pavilions  of  one  or,  at  most, 
two  stories,  in  which  the  buildings  are  entirely  disconnected,  or 
connected  only  by  means  of  an  open  corridor  for  convenience  of 


THE   HOSPITAL   BUILDINGS.  197 

administration,    is  best   for  the   patients,  and,  leaving  out  of 
account  the  cost  of  the  ground,  is  also  the  most  economical. 

The  recent  development  of  the  pavilion  system  of  hospitals 
may  be  attributed  largely  to  the  success  obtained  in  treating  the 
sick  and  wounded  in  the  simple  barrack  hospitals  during  the 
late  war  between  the  States.  The  army  barrack  hospital  is  the 
original  type  of  the  pavilion  hospital  of  the  present  day. 

Each  pavilion  consists  of  one  or  two  wards,  containing 
from  ten  to  thirty  beds  altogether.  In  each  pavilion  or  ward  is 
also  a  bath-  and  wash-  room,  water-closet,  dining-room,  scullery, 
attendants'  room,  and  sometimes  a  day-room  for  patients  able 
to  be  out  of  bed. 

The  two-story  pavilion  is  built  on  the  same  plan,  and  is 
generally  adopted  in  cities,  or  where  economy  of  space  is  desir- 
able for  financial  reasons,  and  where  no  infectious  diseases  are 
treated.  Where  practicable,  one-story  pavilions  should  always 
be  adopted,  as  they  are  more  easily  heated,  ventilated,  and 
served  than  two-storied  buildings. 

When  a  number  of  pavilions  or  wards  are  connected  by  a 
corridor  with  each  other,  and  with  a  central  or  administration 
building  and  other  service  buildings,  the  aggregation  constitutes 
a  modem  pavilion  block-hospital.  The  Johns  Hopkins  Hos- 
pital, already  referred  to,  is  a  model  hospital  of  this  class,  and 
its  plans  should  be  studied  in  detail  by  all  who  are  more  par- 
ticularly interested  in  hospital  construction.  The  general  wards 
are  in  one-  and  two-  story  buildings,  connected  by  a  corridor  with 
each  other  and  with  the  administration  and  service  buildings. 
In  addition  to  two  buildings  containing  private  rooms  and  small 
wards  for  patients  able  to  pay  for  the  extra  accommodations, 
there  is  a  line  of  pavilions  running  from  east  to  west.  The 
corridor  cuts  all  the  pavilions  near  the  north  ends  of  the  build- 
ings, separating  the  ward  almost  entirely  from  the  service  part 
of  the  building.  This  arrangement  leaves  the  south,  east,  and 
west  fronts  of  the  wards  entirely  exposed  to  the  sun's  rays, — 
a  very  important  advantage.  The  kitchen  and  laundry  are  at 


198 


TEXT-BOOK    OF    HYGIENE. 


opposite  angles  of  the  grounds,  while  the  autopsy  building  is 
placed  in  the  extreme  northeast  corner  of  the  grounds,  as  far 
from  all  the  wards  as  practicable. 

The  free  space  between  the  separate  pavilions  should  be  at 


FIG.  18.— PLAN  OF  JOHNS  HOPKINS  HOSPITAL. 

A.  Administration  Building.  B.  Female  Pav-Ward.  C.  Male  Pav-Ward.  D.  Male  Surgical  Ward. 
E.  Female  Surgical  Ward.  F.  Male  Medical  Ward.  G.  Female  Medical  Ward.  H.  Gynecological 
Ward.  I.  Isolating  Ward.  K.  Kitchen.  I,.  Laundry.  N.  Nurses'  Homo.  O.  Dispensary.  R.  Patho- 
logical Building.  S.  Stable.  U.  Amphitheatre.  X.  Apothecary's  Building.  Y.  Bath-IIouse. 

least  twice  the  height  of  the  building.  In  the  Johns  Hopkins 
Hospital,  the  space  is  18  metres  between  the  one-story  common 
wards,  which  are  11  metres  in  height  from  the  surface  of  the 
ground  to  the  ridge  of  the  roof. 


VENTILATION    AND    HEATING.  199 

VENTILATION    AND    HEATING. 

The  cubic  space  (initial  air-space)  per  bed  in  the  wards 
should  not  be  less  than  1500  to  2000  cubic  feet  (42  to  56  cubic 
metres),  and  for  surgical  or  lying-in  cases  and  contagious  dis- 
eases, 70  cubic  metres  should  be  allowed.  The  ventilating 
arrangements  should  secure  an  entire  change  of  the  air  two  to 
three  times  in  an  hour. 

In  most  sections  of  the  United  States,  natural  ventilation 
can  be  relied  on  to  keep  the  air  in  hospital  wards  pure  (assum- 
ing, of  course,  the  proper  construction  of  the  buildings).  The 
windows,  doors,  and  walls  are  important  factors  in  securing  this 
ventilation.  Hence,  especial  care  is  to  be  paid  to  their  con- 
struction and  arrangement. 

Many  German,  French,  and  English  authorities  on  hospital 
building  urge  the  importance  of  making  the  walls  impervious 
by  cement,  glass,  or  paint.  The  peculiar  odor  known  as  "  hos- 
pital odor,"  it  is  asserted,  cannot  be  prevented  in  any  hospital 
in  which  the  floors,  walls,  and  ceilings  are'  not  absolutely  imper- 
vious. The  American  practice  is  generally  in  favor  of  walls 
which  permit  transpiration  of  air.  In  the  experience  of  the 
author  the  imperviousness  of  the  walls  is  not  necessary  to  secure 
freedom  from  hospital  odor.  It  remains  a  question  for  serious 
consideration  whether  the  diminution  of  natural  ventilation 
would  not  counterbalance  any  good  resulting  from  non-absorp- 
tive walls. 

The  interior  of  the  walls  should  be  perfectly  smooth  and 
plain;  no  projections,  cornices,  or  offsets  of  any  kind  are  per- 
missible. The  desirability  of  this  restriction  was  clearly  ex« 
pressed  over  a  hundred  years  ago  by  John  Howard :  "  From 
a  regard  to  the  health  of  the  patients,  I  wish  to  see  plain,  white 
walls  in  hospitals,  and  no  article  of  ornamental  furniture  intro- 
duced."1 

Windows  should  run  quite  to  the  ceiling,  and  should  not 
be  arched,  but  finished  square  at  the  top.  There  should  be  one 

1  An  Account  of  the  Principal  Lazarettos  of  Europe,  etc.,  p.  57.    London,  1791. 


200  TEXT-BOOK   OF   HYGIENE. 

window  for  every  two  beds.  The  window-sash  should  be  double 
to  retain  heat,  and  the  lights  heavy,  clear  glass.  Ventilation 
can  be  promoted  by  raising  the  outer  sash  from  below  and 
lowering  the  inner  one  from  above.  The  insertion  of  a  Sher- 
ringham  ventilator  at  the  top  of  the  inner  sash  will  aid  in  giving 
the  incoming  air-current  an  upward  direction. 

Heating  is  best  accomplished  by  introducing  hot  air  from 
without,  or  by  stoves  or  fire-places  in  the  centre  of  the  wards. 
Where  hot  air  is  introduced  from  without,  it  should  be  heated 
by  passing  it  over  steam-  or  hot-  water  coils,  and  not  by  passing 
it  through  a  furnace,  which  may  produce  super-heating  and 
excessive  dryness  of  the  air. 

In  a  series  of  experiments  by  Dr.  Edward  Cowles  at  the 
Boston  City  Hospital,1  the  air  was  heated  to  32°  by  passing  it 
over  steam-coils.  It  was  admitted  to  the  wards  by  numerous 
inlets  30  centimetres  square.  The  best  velocity  for  ventilating 
and  warming  purposes  was  found  to  be  54  metres  per  minute. 
Exit  openings  were  in  the  ceiling,  and  it  was  found  best  to 
make  them  large,  as  by  this  means  the  rapidity  of  exit  currents 
is  reduced. 

Where  the  warming  of  the  ward  must  be  accomplished  by 
stoves  or  fire-places  in  the  ward,  the  best  plan,  for  square  and 
octagon  wards,  is  to  have  a  large  central  chimney  with  arrange- 
ments on  the  four  sides  for  fire-places  or  stoves.  This  chimney 
can  also  be  used  as  a  very  efficient  ventilating  shaft  throughout 
the  year  by  a  device  put  in  practice  by  Mr.  John  R.  Neirnsee, 
architect  of  the  Johns  Hopkins  Hospital.2  In  oblong  wards, 
two  or  more  large  stoves,  placed  at  equal  distances  along  the 
centre  of  the  wards,  will  heat  the  wards  effectually. 

Floors  should  be  made  of  tiles,  slate,  or  oak  or  yellow-pine 
lumber.  If  wood  is  used,  it  should  be  well  seasoned,  perfectly 
smooth,  and  all  joints  accurately  made.  The  floor  should  be 
kept  constantly  waxed  to  render  it  impervious. to  fluids. 

1  Report  of  the  Massachusetts  State  Board  of  Health  for  1879.  pp.  231-248. 
*  Hospital  Construction  and  Organization :  Plans  for  Johns  Hopkins  Hospital,  p.  335 
et  seq.    New  York,  1875.  ' 


VENTILATION    AND   HEATING.  201 

The  space  between  the  floor  and  ceiling  below  should  be 
filled  with  some  fire-proof  non-conducting  material,  such  as 
cement  or  hollow  bricks,  in  order  to  isolate  each  floor  or  ward 
as  much  as  possible  from  others,  both  to  prevent  transmission 
of  noise  and  extension  of  fire. 

All  corners  and  angles  on  the  inside  of  the  building  should 
be  rounded  to  facilitate  the  removal  of  dust. 

In  cleaning  up,  care  should  be  taken  not  to  stir  up  the 
layers  of  dust  too  much  by  active  sweeping  or  dusting.  The 
floors,  furniture,  door-  and  window-  casings  should  be  wiped  off 
with  damp  cloths.  Soiled  bedding,  clothing,  dressings,  and 
bandages  must  be  promptly  removed  from  the  ward.  Mat- 
tresses and  other  bed-clothing  should  not  be  shaken  in  the  ward.1 

Water-closets  or  (where  the  dry  method  of  removal  of  ex- 
creta is  in  use)  earth-  or  pail-  closets  should  be  placed  where 
they  can  be  easily  reached  by  the  patients,  but  the  apartment  in 
which  they  are  placed  must  not  open  directly  into  the  ward. 
The  entrance  to  this  apartment  should  be  from  the  corridor 
or,  better  still,  from  the  open  air.  The  ventilation  of  water- 
closets  should  be .  independent  of  and  entirely  distinct  from 
that  of  the  ward  or  other  part  of  the  hospital  building. 

It  is,  of  course,  unnecessary  to  more  than  call  attention  to 
the  vital  importance  of  the  prompt  removal  of  all  excreta,  both 
solid  and  liquid,  from  the  ward  or  hospital  building.  To  at- 
tempt disinfection  of  excreta  and  allow  them  to  remain  in  the 
ward  after  being  voided  is  a  pernicious  practice,  which  should 
under  no  circumstances  be  permitted.  All  utensils  for  the  re- 
ception of  excreta,  bed-pans,  etc.,  should  be  immediately  emptied 
and  thoroughly  cleansed. 

Urinals  are  not  advisable ;  the  simple  hopper-closet  with 
hinged,  hard-wood  seat,  as  described  in  Chapter  VI,  is  sufficient. 

A  bath-room  and  lavatory  should  be  attached  to  every 
ward.  It  should  be  placed  in  the  service  building,  and  be 

'A  Wornioh  :  Ueber  Verdorbene  Luft  in  Krankenraeumen.  Volkmann's  Samml.  Klin. 
Vortr.,  No.  179,  p.  24. 


202  TEXT-BOOK   OF   HYGIENE. 

easily  accessible  to  the  patients.  There  should  also  be  portable 
bath-tubs  in  order  that  baths  may  be  given  in  the  wards  when 
necessary. 

Every  large  general  hospital  should  also  have  a  special 
apartment  or  building  where  baths  of  various  kinds,  such  as 
medicated,  vapor,  Turkish,  and  Russian  baths,  could  be  given. 
In  lying-in  hospitals,  special  arrangements  for  giving  vaginal 
and  uterine  douches  must  also  be  furnished. 

A  daily  water-supply  of  at  least  450  litres  per  bed  should 
be  provided.  The  water  should  be  easily  accessible  from  the 
wards  and  various  parts  of  the  service  building. 

All  water-closets,  soil-  and  waste-  pipes  must  be  properly 
trapped ;  all  joints  must  be  properly  made  and  all  sewer  con- 
nections made  on  the  most  improved  plans.  All  work  of  this 
sort  should  be  properly  tested  before  being  accepted,  and 
frequently  inspected  afterward. 

No  sewer  or  house-drain  should  be  laid  under  a  ward. 

A  disinfecting  chest  for  disinfecting  soiled  clothing,  bed- 
ding, dressings,  etc.,  should  be  placed  in  the  basement  of  the 
ward,  and  connected  with  the  latter  by  an  iron  chute,  closing 
perfectly  by  an  iron  top.  The  best  and  most  convenient  disin- 
fectant is  steam.  This  is  also  the  best  means  to  destroy  vermin 
in  clothing  and  bedding. 

It  is  questionable  whether  a  nurse's  room  should  be 
attached  to  a  hospital  ward.  The  nurse's  place,  when  on  duty, 
is  in  the  ward  itself,  not  in  a  room  separate  from  it.  Where 
there  is  a  nurse's  room,  it  should  not  be  furnished  with  sleeping 
arrangements,  for  this  is  a  strong  temptation  to  neglect  of  duty 
on  the  part  of  the  nurse.  A  nurse  not  on  duty  should  not  be 
permitted  to  remain  about  the  ward. 

A  ward-kitchen  should  be  in  the  service  building,  where 
articles  of  food  can  be  kept  hot  or  cold  when  necessary,  and 
where  special  dressings,  cataplasms,  hot  water,  etc.,  can  be  pre- 
pared. A  small  gas-stove  only  should  be  allowed  in  the  ward- 
kitchen,  as  the  regular  meals  of  the  patients  are  prepared  in  the 


ADMINISTRATION  AND  MANAGEMENT  OF  A  GENERAL  HOSPITAL.       203 

central  kitchen,  which  should  be  totally  detached  from  the 
hospital.  The  ward-kitchen  can  be  easily  utilized  as  a  nurse's 
room,  and  in  a  small  hospital  can  also  be  used  as  a  store-room 
for  the  patients'  body-  and  bed-  linen  and  clothing. 

The  dining-room  for  patients  able  to  be  out  of  bed  should 
be  in  the  service  building.  A  room  with  a  good  light  and  well 
ventilated  and  heated  should  be  selected  for  this  purpose.  In 
the  intervals  between  meals  this  room  could  be  used  as  a  day- 
room  for  such  patients  as  should  be  out  of  bed,  but  who  are  not 
able  to  be  in  the  open  air. 

A  dead-house,  containing  a  dead-room,  autopsy-room,  and 
a  room  fitted  up  for  rough  microscopic  and  possibly  photo- 
graphic work,  is  a  necessity  to  every  well-appointed  general 
hospital.  The  dead-house  should  be  entirely  separate  from  the 
ward  buildings. 

The  kitchen  should  be  separate  from  the  other  buildings, 
and  in  large  hospitals  should  also  be  the  central  station  for  the 
•heating  arrangements,  if  hot  water  or  steam  are  to  be  used.  The 
laundry  may  be  connected  with  it.  The  kitchen  should  be  con- 
nected with  the  wards  by  means  of  a  covered  corridor  to  avoid 
exposure  in  carrying  the  food  to  the  wards. 

The  administration  building  should  contain  office-rooms 
for  the  superintendent  and  resident  physician,  pharmacy,  library, 
reception-rooms  for  visitors,  living-rooms  for  one  or  more  assist- 
ants, and  dwellings  for  the  superintendent  and  resident  physician. 

THE    ADMINISTRATION    AND    MANAGEMENT   OF  A  GENERAL   HOSPITAL. 

The  general  management  of  a  hospital  should  be  under  the 
direction  of  a  superintendent,  who,  besides  being  a  medical  man, 
should  be  especially  qualified  by  study  and  experience  for  the 
work.  The  superintendent  of  a  large  hospital  should  not  be 
expected  to  perform  any  of  the  routine  professional  work  in  the 
wards,  but  he  should  be  responsible  for  the  service,  both  profes- 
sional and  lay,  in  the  hospital.  He  should  be  the  financial 
officer,  and  in  all  other  things  concerning  the  hospital  his 


204  TEXT-BOOK   OF   HYGIENE. 

judgment  should  decide.  He  should  have  sufficient  assistance 
to  permit  all  necessary  duties  to  be  promptly  performed.  For 
this  purpose  he  should  have  a  secretary,  or  clerk,  who  should 
not  be  a  medical  man;  otherwise  the  attention  of  the  latter 
might  be  withdrawn  from  his  clerical  duties  to  the  more  inter- 
esting professional  work  in  the  hospital.  The  plan  advocated 
by  some  authorities,  to  have  two  superintendents  for  large  hos- 
pitals,— one  of  whom  shall  be  a  medical  man  and  direct  only  the 
professional  work  of  the  hospital,  while  the  other  shall  have 
charge  of  the  administrative  functions, — does  not  commend  itself 
to  the  author.  It  involves  a  division  of  responsibility  which  will, 
in  nearly  all  cases,  eventually  lead  to  differences  of  opinion 
likely  to  prove  unfavorable  to  the  best  interests  of  the  hospital. 

It  is  customary  in  this  country  to  appoint  as  resident  physi- 
cians and  surgeons  in  hospitals,  recent  graduates,  whose  functions 
are  usually  limited  to  carrying  out  the  directions  of  the  visiting 
physicians  and  surgeons,  and  sometimes  to  act  on  their  own 
responsibility  in  emergencies.  This  system  has  some  advantages 
for  the  physicians,  but  is  usually  detrimental  to  the  best  interests 
of  the  patients.  The  resident  medical  officer  in  a  large  hospital 
should  always  be  a  thoroughly  qualified,  experienced  physician, 
capable  of  deciding  promptly  when  the  occasion  arises,  and  he 
should  be  responsible  to  the  superintendent  for  the  proper  per- 
formance of  his  professional  duties.  Necessarily,  a  physician 
with  the  qualifications  indicated,  would  demand  a  very  much 
larger  salary  than  is  usually  paid  resident  physicians,  but  it 
should  be  understood  that  no  hospital  in  which  the  good  of 
the  patient  is  the  first  consideration  can  be  conducted  on  a  cheap 
basis. 

Visiting  physicians  and  surgeons  and  all  resident  medical 
officers  should  be  chosen  with  reference  to  their  general  and 

o 

special  qualifications  for  the  duties  expected  of  them.  It  would 
seem  to  be  a  good  plan  to  make  the  selections  for  subordinate 
positions,  at  least,  by  competitive  examination. 

The  sick  in  a  hospital  should  be  properly  classified.     Male 


ADMINISTRATION  AND  MANAGEMENT  OF  A  GENERAL  HOSPITAL.     205 

and  female  patients  should,  of  course,  be  treated  in  separate 
wards.  A  primary  classification  into  medical,  surgical,  and 
obstetrical  cases  or  wards  is  also  indicated.  Infectious  dis- 
eases, such  as  typhoid  fever,  erysipelas,  cholera,  yellow  fever, 
croupous  pneumonia,  etc.,  should  not  be  treated  in  the  same 
wards  with  rheumatism,  Bright's  disease,  cardiac  and  nervous 
disorders,  or  simple  digestive  derangements.  It  is  questionable, 
however,  whether  it  is  advisable  to  make  a  very  elaborate  classi- 
fication of  the  various  diseases  except  in  very  large  hospitals. 

An  accurate  record,  made  at  the  time  of  observation,  and 
not  written  from  memory  afterward,  should  be  kept  of  the  his- 
tory and  progress  of  every  case.  The  record  should  show  not 
merely  the  symptoms  and  diagnosis,  but  the  medical  and  hy- 
gienic treatment.  In  most  hospitals  where  such  records  are 
kept  the  entries  are  made  either  in  a  simple  memorandum-book 
or  in  a  more  or  less  complicated  case-record.  A  simple  form 
of  case-record  has  been  devised  by  Surgeon-General  Walter 
Wyman,  of  United  States  Marine-Hospital  Service,  which  seems 
to  possess  advantages  that  render  its  general  adoption  desirable. 

In  hospitals  where  cases  of  surgical  diseases  and  injuries  are 
received,  a  special  apartment  should  be  fitted  up  as  an  operating- 
room.  Operations  should  not  be  performed  in  award  in  the 
presence  of  other  patients. 

[The  following  works  are  recommended  for  additional  study 
upon  this  subject:  — 

Hospital  Construction  and  Organization  ;  New  York,  1875  (espe- 
cinll}'  the  essays  of  Drs.  Billings,  Folsom,  and  Stephen  Smith). — Kran- 
kenanstalten,  by  L.  Degen,  in  Y.  Pettenkofer  und  Ziemssen's  Hand- 
buch  der  Hygiene. — Spital,by  C.  Bohm,in  Realencyclopadie  d.  ges.  Heil- 
kunde,  Bd.  XII. — General  Principles  of  Hospital  Construction,  by  F.  H. 
Brown,  in  Buck's  Hygiene  and  Public  Health,  vol,  i. — Schumburg, 
Hygienische  Grundsatze  beirn  Hospitalbau.] 


QUESTIONS   TO   CHAPTER  VII. 

CONSTRUCTION  OF  HOSPITALS. 

What  would  govern  you  in  selecting  a  site  for  a  hospital  ?  What 
will  go  to  determine  the  building  area  ?  In  calculating  the  area  required 
for  buildings,  what  relation  has  it  to  the  number  of  beds  in  the  hospital  ? 
In  the  wards,  what  should  be  the  actual  minimum  floor-space  for  each 
bed  for  non-infectious  and  for  infectious  diseases  ?  What  is  the  differ- 
ence in  the  principles  of  modern  hospital  construction  and  of  those  for- 
merly in  vogue  ?  What  are  some  of  the  advantages  of  the  modern  plan  ? 
What  was  the  prototype  of  the  present  system?  How  many  wards 
should  each  pavilion  contain  at  the  most  ?  How  many  beds  in  each 
ward?  What  conveniences  should  there  be  in  each  ward  or  pavilion? 
What  is  meant  by  a  pavilion  block-hospital  ?  What  space  should  there 
be  between  the  separate  pavilions? 

What  cubic  space  per  bed  should  there  be  in  the  ordinary  wards  ? 
What  cases  need  more,  and  how  much  ?  How  often  should  the  air  be 
entirely  changed  in  the  wards  ?  Should  the  walls  be  pervious  or  imper- 
vious to  the  passage  of  air  ?  How  should  the  walls  be  finished  ?  How 
many  windows  should  there  be  in  each  ward  ?  How  high  should 
they  be  ? 

What  is  the  best  way  to  heat  a  hospital  ward  ?  How  should  hot  air 
be  warmed  ?  If  a  ward  is  to  be  warmed  by  fire-places  or  stoves,  how 
should  they  be  arranged  ? 

Of  what  materials  should  the  floors  be  made  ?  How  should  they  be 
treated  ?  What  should  there  be  between  ceilings  and  the  floors  above  ? 
Why?  How  should  the  corners  and  angles  of  floors  and  ceilings  be 
finished  ? 

How  should  the  wards  be  cleaned  ?  What  should  be  done  with 
soiled  bedding,  etc.  ? 

Where  should  the  water-closets,  etc.,  be  located  ?  How  should  they 
be  ventilated  ? 

How  much  water  should  be  furnished  per  bed?  Why  should  no 
sewer  or  house-drain  be  laid  under  a  ward  ?  Where  should  the  nurses' 
rooms  be?  Where  the  ward  kitchen  and  dining-room?  What  is  the 
administration  building  for,  and  what  should  it  contain  ?  What  officers 
are  necessary  for  the  management  of  a  hospital  ?  What  are  their  duties  ? 
How  should  the  resident  physicians  be  qualified  and  selected?  How 
should  the  sick  be  classified,  and  what  wards  should  there  be  in  a  general 
hospital  ?  Mention  some  of  the  details  that  should  be  noted  in  the  case 
records. 

(206) 


CHAPTER  VHI. 

SCHOOLS. 

THE  hygiene  of  schools  comprises  the  consideration  of  the 
sanitary  principles  underlying  the  construction  of  school-houses 
and  school-furniture;  the  proper  amount  of  time  to  be  devoted 
to  study  at  different  ages ;  the  special  diseases  of  school-children, 
their  causes,  and  means  for  their  prevention. 

CONSTRUCTION    OF   SCHOOL-HOUSES. 

In  the  construction  of  school-houses  the  same  hygienic 
principles  are  applicable  as  in  dwelling-house  construction.  The 
selection  of  a  site  for  the  school-building  should  command  the 
same  careful  consideration  that  is  necessary  in  determining  upon 
a  site  for  a  dwelling.  Proximity  to  marshes  and  other  unsan- 
itary surroundings  should  be  avoided.  If  the  soil  is  damp  it 
should  be  properly  drained,  and  all  sources  of  insalubrity  in  the 
neighborhood  avoided  or,  if  possible,  removed. 

School-houses  should  not  be  over  three  stories  high ;  cor- 
ridors and  stairways  should  be  wide,  straight,  and  well  lighted. 
All  stairs  should  be  securely  built,  and  be  guarded  with  ample, 
strong  railing.  All  doors  should  open  outward  to  permit  ready 
egress  and  reduce  the  danger  of  accident  in  panics  from  any 
cause. 

In  addition  to  the  study-  or  recitation-  rooms,  provision 
should  be  made  for  play  and  calisthenic-exercise  rooms.  Well- 
lighted  and  ventilated  side-rooms  should  be  provided  for  the 
reception  of  outside  clothing,  umbrellas,  overshoes,  etc.  These 
articles  should  not  be  kept  in  the  recitation-  or  study-  rooms. 

Floors  should  be  made  of  accurately-joined  flooring,  and 
rendered  impervious  by  oil  or  paraffine  coating. 

(207) 


208  TEXT-BOOK   OF   HYGIENE. 

Appropriate  measures  must  be  employed  to  prevent  the 
permeation  of  the  building  by  ground-air. 

The  inside  walls  of  school-rooms  may  be  tinted  a  neutral 
gray,  or  light  blue  or  green.  Ceilings  should  be  white.  Walls 
and  ceilings  should  not  be  painted,  but  lime-coated  to  permit 
free  transpiration  of  air. 

Schools  should  be  so  constructed  as  to  permit  of  ready 
heating  and  ventilation,  cleaning,  and  keeping  clean.  In  large 
schools  the  method  of  heating  will  usually  be  by  furnace-heated 
air,  although  a  better  method  would  probably  be  by  steam- 
or  hot- water  pipes. 

The  ventilation  of  school-rooms  must  be  carried  out  on  the 
principles  indicated  in  Chapter  I.  With  careful  and  intelligent 
teachers,  natural  ventilation  will  give  better  satisfaction  than  a 
complicated  artificial  system.  Where  windows  and  doors  must 
be  largely  depended  upon  for  ventilation,  the  Bury  window  ven- 
tilator, illustrated  on  a  previous  page,  will  give  satisfactoiy  results 
unless  the  school-room  is  overcrowded.  Opening  the  doors  and 
windows  when  the  pupils  are  out  of  doors — flushing  the  rooms 
with  fresh  air — is  an  excellent  aid,  and  is  even  useful  in  cases 
where  the  most  elaborate  artificial  system  of  ventilation  is  in  use. 

A  model  study-room,  according  to  modern  views,  should 
be  about  9  to  10  metres  long,  not  over  7  metres  wide,  and  4  to 
4^  metres  high.  Such  a  room  could  be  easily  lighted  by  win- 
dows on  one  side  only,  and  readily  heated  and  ventilated.  It 
would  also  enable  the  teacher  to  exercise  a  close  supervision 
over  his  pupils.  In  a  room  of  this  size  forty  pupils  would  be  a 
proper  number,  although  fifty  could  be  accommodated.  The 
initial  air-space  for  each  pupil  would  be  5.60  cubic  metres  if 
there  were  fifty  pupils  in  the  room,  and  7  cubic  metres  if 
there  were  only  forty.  This  would  be  slightly  reduced  by  the 
allowance  for  the  teacher. 

It  is  believed  that  study-rooms  should  face  toward  the 
north.  The  light  entering  from  the  north  side  of  a  building 
would  be  equable  during  a  whole  day.  While  a  larger  window 


CONSTRUCTION   OF   SCHOOL-HOUSES.  209 

surface  would  be  necessary  than  with  an  easterly  or  southerly 
exposure,  it  is  held  that  the  light,  being  devoid  of  all  glare, 
would  be  more  effective.  Where  the  light  is  admitted  on  the 
east,  south,  or  west  sides  of  the  building,  the  direct  entrance  of 
the  sun's  rays  must  be  prevented  by  curtains,  by  means  of  which 
the  amount  and  proper  distribution  of  the  light  is  regulated 
with  difficulty. 

The  windows  of  the  school-room  should  reach  from  about 
the  height  of  the  pupil's  shoulder  (when  seated)  to  nearly  or 
quite  to  the  ceiling.  Arches  or  overhanging  cornices  over  the 
windows  should  be  avoided,  as  they  cut  off  much  light.  For 
the  same  reason  the  near  proximity  of  other  high  buildings 
and  of  trees  should  be  avoided  in  selecting  a  site  for  a  school- 
house.  The  window  area  should  be  not  less  than  one-fifth  of 
the  floor  area,  otherwise  the  light  will  be  deficient. 

The  light  should  be  admitted  only  from  the  left  side  of  the 
pupil.  When  admitted  from  the  right  side  the  shadow  cast  oy 
the  pen  in  writing  interferes  with  good  vision ;  if  admitted 
directly  in  front  of  the  pupil,  the  glare  of  the  light  will  injuri- 
ously affect  the  eyes ;  while,  if  it  enter  from  behind,  the  book 
or  paper  of  the  pupil  will  be  so  much  in  shadow  as  to  compel 
him  to  lean  so  far  to  the  front  in  bringing  his  eyes  nearer  to 
book  or  paper  that  nearsightedness  is  very  likely  to  be  devel- 
oped. Furthermore,  if  the  light  is  admitted  into  the  room  at 
the  backs  of  the  pupils,  the  eyes  of  the  teacher  are  liable  to 
suffer  from  the  constant  glare. 

In  a  school-room  of  the  dimensions  above  stated,  a  row  of 
windows  on  one  side,  forming  an  area  of  glass  one-fifth  of  the 
floor-space,  will  thoroughly  and  satisfactorily  illuminate  the 
room,  with  the  least  unfavorable  influence  upon  the  organs  of 
vision.  It  is  advisable,  therefore,  to  always  insist  on  this 
arrangement  of  lighting  of  school-rooms.  Where  artificial 
light  is  used  in  a  school-room,  it  should  be  in  the  proportion 
of  one  burner  to  every  four  pupils.  All  burners  should  be 
provided  with  chimneys  and  vertical  reflectors. 


u 


210  TEXT-BOOK   OF    HYGIENE. 

Water-closets  and  privies  should  not  be  placed  in  cellars  or 
basements.  This  would  seem  to  be  self-evident,  and  yet  in 
many  city  school-houses  these  places  of  retirement  are  in  this 
unsuitable  location.  When  it  is  considered  that  large  schools 
are  frequently  warmed  by  hot  air  taken  from  the  cellar,  it 
furnishes  an  additional  reason  to  avoid  this  location  for  water- 
closets.  On  the  contrary,  the  custom,  in  some  country  schools, 
of  placing  the  privy  at  a  considerable  distance  from  the  school- 
room and  in  an  exposed  situation,  is  almost  equally  reprehen- 
sible, as  the  pupils,  especially  girls,  are  prone  to  neglect  obeying 
the  calls  of  nature,  from  which  neglect  many  disorders  arise. 

In  a  recently-introduced  system  of  ventilation  and  excre- 
ment removal  for  schools,  the  closets  are  in  the  basement,  and 
the  excrement,  as  Yoided,  is  rapidly  dried  by  a  current  of  air, 
and  the  odor  in  this  way  quickly  destroyed.  Unfortunately,  in 
thus  drying  the  excrementitious  matter,  micro-organisms  may 
be  taken  up  in  the  air-currents  and  carried  into  the  school-rooms. 

SCHOOL   FURNITURE. 

Desks  should  be  slightly  sloping,  the  edge  nearest  the  pupil 
being  about  1  inch  (2.5  centimetres)  higher  than  his  elbows. 
The  front  edge  of  the  seat  should  project  a  little  beyond  the 
near  edge  of  the  desk,  so  that  a  plumb-line  dropped  from  the 
latter  should  strike  the  seat  near  its  front  edge.  If  the  seat  is 
not  thus  brought  slightly  under  the  desk,  the  pupil  is  compelled 
to  lean  forward  in  writing,  which  position  prevents  proper  ex- 
pansion of  the  chest  and  increases  the  blood-pressure  in  the 
eyes, — a  condition  promotive  of  near-sightedness. 

Seats  should  be  only  high  enough  so  that  the  feet  rest  flat 
upon  the  floor.  If  they  are  higher,  a  foot-board  must  be  pro- 
vided. Children  should  not  be  condemned  to  the  cruelty  of 
having  their  feet  dangling  "  between  heaven  and  earth  "  while 
they  keep  their  seats.  Seats  and  desks  should  be  graded 
according  to  the  sizes  of  the  pupils — not  their  ages  or  standing 
hi  the  class. 


SCHOOL   FURNITURE. 


211 


An  ideal  seat  and  desk  would  be  one  made  to  measure  for 
each  pupil,  but  this  is  manifestly  impracticable,  inasmuch  as 
with  the  constant  growth  of  the  child  the  seats  would  be  rapidly 
outgrown. 

The  desk  shown  in  Fig.  19 l  is  adjustable  to  children  of 
different  sizes,  and  seems  to  solve  the  problem  which  has  so  long 
puzzled  the  school  sanitarian.  The  desks  are  made  for  a  single 
pupil  and  the  seat  and  desk  are  independently  adjustable. 


FIG.  19.— ADJUSTABLE  SCHOOL-DESK.    (Front  View.) 

t 

The  frame  is  of  iron  and  the  seat,  back,  and  desk  of  hard-wood 
lumber. 

Blackboards  should  not  be  placed  at  a  greater  distance  than 
10  metres  from  the  farthest  pupil.  The  ground  of  the  board 
should  be  a  dead  black,  without  lustre.  In  writing  exercises 
upon  the  board,  care  should  be  taken  that  the  letters  and  figures 
are  made  sufficiently  large,  and  with  rather  heavy  strokes  of  the 
crayon,  in  order  that  they  may  be  easily  seen  from  the  most  distant 
part  of  the  room.  It  has  recently  been  demonstrated  that  a  black 
letter  on  a  white  ground  can  be  seen  at  a  greater  distance  than 

1  Made  by  the  Rushville  School  Furniture  Company,  Rushville,  Ind.,  U.  S.  A. 


212  TEXT-BOOK   OF   HYGIENE. 

a  white  letter  on  a  black  ground.  Hence,  it  might  prove 
advantageous  to  the  eye-sight  of  school-children  to  substitute 
for  the  present  blackboard  and  chalk,  a  white  board  and  black 
crayon.  In  some  European  lecture-rooms  this  plan  has  been 
adopted  with  satisfaction. 

AMOUNT   OF   TIME   TO   BE   DEVOTED   TO   STUDY. 

Young  children  should  not  be  kept  at  the  same  study  or 
in  the  same  position  for  long  at  a  time.  The  exercises  should 
be  frequently  varied.  It  is  especially  with  children  in  the 
primary  grades  that  care  should  be  taken  not  to  overburden 
their  minds  with  too  many  hours  of  study,  or  too  long  con- 
tinuance at  the  same  exercise. 

Children  should  not  be  placed  in  school  much,  if  at  all, 
before  the  completion  of  their  7th  year.  From  7  to  9  years 
they  should  be  kept  at  their  studies  not  longer  than  three  hours 
daily;  from  9  to  12  years  four  hours  may  be  allotted  them;  and 
from  12  to  16  years  they  may  be  kept  at  mental  work  five  to  six 
hours  daily.  This  does  not  mean  that  pupils  are  to  be  kept 
continuously  at  their  studies  during  these  hours,  but  that  they 
should  be  neither  compelled  nor  permitted  to  study  longer  than 
these  periods  each  day.  It  is  believed  that  these  figures  repre- 
sent the  capacity  for  endurance  in  the  majority  of  children,  and 
they  .should  be  adopted  in  all  schools  where  the  largest  return 
in  mental  acquirements  is  desired  at  the  least  expenditure  of 
health.  Excess  of  time  expended  in  study  is  almost  certainly 
followed  by  physical  deterioration.  "  A  little  less  brain :  a  little 
more  muscle,"  for  our  children,  is  a  legitimate  demand  that  we 
may  make  of  legislators  and  school-boards. 

Gymnastic  exercises  should  form  part  of  the  daily  routine 
in  all  schools.  These  exercises  should  take  place,  when  practi- 
cable, in  the  open  air.  Playing,  romping,  laughing,  and  sing- 
ing should  be  encouraged,  rather  than  the  natural  tendency 
to  boisterous  play  restrained.  It  is  especially  desirable  that 
female  children  should  be  encouraged  to  take  part  in  these 


DISEASES   OF    SCHOOL-CHILDREN.  213 

diversions.  The  desire,  on  the  part  of  many  parents,  to  see 
little  girls  deport  themselves  as  young  ladies,  before  the  time 
even  when  they  write  their  age  in  two  figures,  is  very  rep- 
rehensible, and  deserves  the  most  unqualified  condemnation. 
Moliere's  satirical  remark,  "  II  n'ya  plus  d'enfants,"  seems  to 
be  literally  true  at  the  present  day. 

DISEASES   OF   SCHOOL-CHILDREN. 

The  principal  diseases  incident  to  school-life  are  myopia, 
spinal  deformities,  nervous  and  digestive  disorders,  pulmonary 
phthisis,  and  contagious  diseases.  It  is  believed  that  by  judi- 
cious sanitary  measures  these  can  all  be  very  much  diminished 
and  some  entirely  prevented. 

It  has  been  shown  by  the  examination  of  the  eyes  of  school- 
children that  near-sightedness  increases  progressively  from  the 
lowest  to  the  highest  classes.  Children  who  enter  school  with 
an  hereditary  tendency  to  myopia,  or  who  are,  perhaps,  already 
near-sighted  to  a  slight  degree,  soon  become  more  intensely 
myopic ;  while  others,  who  may  be  even  hypermetropic  on  enter- 
ing school,  will  be  found  to  have  become  near-sighted  during 
school-life.  In  examinations  of  over  30,000  pupils  of  grammar 
and  high  schools  in  Germany,  Austria,  Russia,  and  Switzerland, 
it  has  been  found  that  the  average  proportion  of  near-sightedness 
is  a  fraction  over  40  per  cent.,  varying,  in  the  different  classes, 
from  22  per  cent,  for  the  lowest  to  58  per  cent,  for  the  highest 
classes.  These  figures  represent  the  averages  of  all  the  ex- 
aminations made.  In  some  particular  schools,  for  example  in 
the  gymnasium  (high  school)  of  Erlangen,  the  percentage  in  the 
higher  classes  was  88  per  cent.,  in  the  gymnasium  of  Coburg 
86  per  cent.,  and  in  the  gymnasium  of  Heidelberg  the  propor- 
tion of  myopic  students  in  the  highest  class  is  said  to  have 
reached  100  per  cent,  in  1877.  In  the  primary  schools  the  per- 
centage wras  found  to  be  much  lower.  Recent  investigations  in 
the  schools  of  Stockholm,  by  Widmark,  show  that  among 
school-children  examined  under  7  years  of  age  there  was  no 


214 


TEXT-BOOK   OF   HYGIENE. 


myopia.  In  the  higher  classes  the  myopia  increases  not  only 
in  degree,  but  in  frequency.  The  diagrams,  Figs.  20  and  21, 
show  graphically  the  increase  in  degree  and  frequency  of 
myopia  in  the  several  school-classes.  These  observations  show 
that  the  number  of  myopic  individuals  bears  a  constant  relation 
to  the  intensity  of  use  of  the  visual  organs.  The  results  of  the 
observation  of  different  observers  in  different  countries  also 


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"•"*"  r  T 

::::  S:  ;::::::::::::::  :||  :::|  fcp  ^ 

::  :::::  ;•  ]|  :  ::;  :: 

jijjiijjjjjjiijjjjjij 

-.---< 

!;::l;-iil:::iij!:jh 

E==;i=Jllllll^:|lfEE;i; 

::;;  ;  •=:  rfrr  rr1  Jstn  &~  tf"  ^r^  t 

SS3^^; 

-   T  T^l    :  '  '  •   "3d      ffl     T     -^----F-r 

:Sx::::::::::::::::::::B:±i:::^;;:  J 

:::  ::::::3^:  ::;:: 
1     !i:jhQ        1 

-•:-•••';  ^-fr- 

ff:::::^::;;;;;;;:;;;;;^^:;;;:--- 

--•  •  ••  •-!  • 

FIG.  20.— MYOPIA  ACCORDING  TO  SCHOOL-CLASSES— BOYS. 

uniformly  point  to  the  conclusion  that  not  only  does  the  number 
of  near-sighted  pupils  increase  as  the  higher  classes  are  reached, 
but  the  degree  of  myopia  increases  likewise.  Thus,  a  pupil 
who  may  have  only  a  moderate  degree  of  myopia  on  entering 
the  school  will  have  myopia  in  a  higher  degree  as  he  advances 
in  his  classes.  Erismann  found,  on  re-examining  the  same 
pupils  annually,  that  in  six  years  13.14  per  cent,  of  those  ex- 
amined had  developed  myopia  from  emmetropia,  while  in  24.57 


DISEASES   OF    SCHOOL-CHILDREN. 


215 


per   cent,  of    near-sighted   pupils  the  degree   of  myopia  had 
increased.1 

The  principal  causes  of  the  prevalence  of  near-sightedness 
in  schools  are  badly-arranged  or  insufficient  light,  bad  air,  over- 
heating of  the  school-rooms,  improper  construction  of  desks 
compelling  children  to  lean  forward  while  reading  or  writing, 
and  badly-printed  text-books.  The  use  of  small  type,  poor 
paper,  and  bad  press-work  in  text-books  is  very  reprehensible. 
The  type  technically  known  as  Long  Primer  is  the  smallest  that 


Class  J 

7  u  in  iv  v  vi  n 

ivwrx  Class. 

.<>:...!---. 

....--..-'--i  

.  .  ,.!_.  .....  --i-  .---. 

FIG.  21.— MYOPIA  ACCORDING  TO  SCHOOL-CLASSES—GIRLS. 

should  be  used  in  text-books.  That  badly-arranged  light  and 
improper  seats  are  causes  of  myopia  has  been  shown  by  Flor- 
schutz  in  his  examinations  of  the  pupils  in  the  public  schools 
of  Coburg.  He  found  that  in  the  newer  schools,  in  which  the 
light  and  seats  are  better  arranged,  the  percentage  of  near-sight 
decreased.  The  average  percentage  of  those  examined  in  1874 
was  21,  while  in  1877  it  had  been  reduced  to  15,2  showing 

1  Erismann,  Die  Hygiene  der  Schule,  in  von  Pettenkoffer  und  Ziemssen's  Handbuch  der 
Hygiene,  II  Tli.,  2  Abtli..  p.  30. 

1  Quoted  by  Colin  in  Realencyclopaedie  d.  ges.  Heilk.,  Bd.  XII,  p.  263. 


216  TEXT-BOOK   OF   HYGIENE. 

the  great  improvement  due  to  the  application  of  correct  sanitary 
principles  in  the  construction  of  school-houses. 

Defective  hearing  has  recently  been  shown  to  be  especially 
frequent  among  school-children.  A  Berlin  aurist  found  1392 
children  out  of  5902  (23.6  per  cent.)  suffering  from  ear  disease 
of  some  kind.  Dr.  Samuel  Sexton,  of  New  York,  and  the  late 
Dr.  Chas.  F.  Percivall,  director  of  music  in  the  public  schools 
of  Baltimore,  have  arrived  at  similar  results  after  examination 
of  a  large  number  of  school-children. 

Spinal  curvature  is  present  in  a  large  proportion  of  the 
children  attending  schools.  Statistics  are  not  very  full  upon 
this  subject,  but  one  author,  Guillaume,  states  that  he  found 
lateral  curvature  of  the  spine  in  218  out  of  731  school-children, 
— a  proportion  of  29.5  per  cent.  This,  of  course,  includes  the 
slighter  degrees  of  curvature,  which  cannot  properly  be  termed 
a  disease.  Among  30,000  Danish  school-children  13  per  cent. 
had  some  variety  or  degree  of  spinal  deformity.  M.  Eulen- 
burg1  found  that  among  1000  persons  with  lateral  curvature  of 
the  spine,  the  disease  began  in  887  between  the  ages  of  6  and 
14;  that  is  to  say,  during  the  years  of  school-life.  Girls  are 
affected  more  than  ten  times  as  often  as  boys,  the  proportion 
being  93.43  per  cent,  in  the  former  and  only  6.57  per  cent,  in 
the  latter. 

The  especial  causes  of  spinal  curvature  occurring  during 
school-life  are  improperly-constructed  seats  and  desks  and  an 
improper  position  of  the  body.  Many  pupils  habitually  assume 
a  "  twisted  "  position,  which  is  very  liable  to  produce  spinal  dis- 
tortion in  children  of  weak  muscular  development.  The  manner 
in  which  a  desk  that  is  too  high  for  the  pupil  may  produce 
spinal  distortion  is  very  well  shown  in  Fig.  22.  An  improper 
position  is  more  likely  to  be  unconsciously  assumed  by  girls  than 
by  boys.  The  clothing  is  responsible  for  this,  for  when  the  girl 
files  into  her  place  behind  the  desk,  her  clothing,  hanging 
loosely  about  her,  is  swept  back  and  forms  a  pad,  upon  which 

1  Realencyclopaedie  d.  ges.  Heilk.,  Bd.  XI,  p.  5&4. 


DISEASES   OF    SCHOOL-CHILDREN. 


217 


she  sits  with  one  buttock.  The  greater  elevation  of  her  seat 
on  that  side  throws  the  spinal  column  out  of  the  vertical  line, 
which  is  compensated  by  a  partial  twisting  of  the  trunk.  The 
attention  of  teachers  should  be  directed  to  this  faulty  habit, 
which  can  be  easily  corrected,  and  its  consequences  averted  by 
timely  interference. 

Nervous  disorders  are  comparatively  frequent  among  school- 
children. Headaches  are  often  due  to  insufficient  ventilation, 
improper  food,  bad  digestion,  and  excessive  mental  strain. 
Defective  light  may  also  be  the  cause  of  headaches  by  causing 


FIG.  22.— SHOWING  INFLUENCE  OF  A  HIGH  DESK  IN  CAUSING  SPINAL  CURVATURE. 

ocular  fatigue.  Hysterical  and  imitative  affections  are  not 
infrequent,  and  sometimes  pass  through  entire  schools,  including 
even  the  teachers.  Girls  are,  of  course,  more  subject  to  this 
class  of  disorders  than  boys,  but  the  latter  are  not  entirely 
exempt. 

Derangements  of  the  digestive  organs  are  exceedingly 
frequent  among  school-children.  They  can  generally  be  traced 
to  the  use  of  improper  food.  The  eating  of  cold  lunches  should 
be  discouraged  as  much  as  possible. 

Nuts,  candies,  pies,  fruit-cakes,  and,  above  all,  pickles  are 


218  TEXT-BOOK   OF   HYGIENE. 

most  fruitful  sources  of  digestive  derangements  of  children. 
The  absence  of  proper  accommodations  to  enable  children — 
especially  girls — to  answer  the  demands  of  nature  are  frequent 
sources  of  digestive  and  nervous  disorders. 

The  seeds  of  pulmonary  consumption  are  frequently  im- 
planted during  school-life.  A  neglected  cough  ;  bad  ventilation, 
under  which  term  may  be  comprised  overheating  and  cold 
draughts,  as  well  as  polluted  air;  improper  position  of  the 
body,  excessive  mental  work,  or  underfeeding,  may,  any  of 
them,  be  the  starting-point  of  this  fatal  disease. 

Especial  care  should  be  taken  to  prevent  the  introduction 
or  dissemination  of  contagious  diseases  through  schools.  The 
importance  of  this  duty  should  be  at  all  times  impressed  upon 
school-boards  and  teachers.  In  the  first  place,  no  child  should 
be  admitted  within  the  door  of  the  school-room  unless  it  first 
presents  undoubted  evidence  of  protection  against  small-pox, 
either  by  having  passed  through  a  previous  attack  or  by  a 
proper  vaccination.  In  case  of  an  actual  or  threatened  epidemic 
of  small-pox  the  entire  school,  including  teachers,  should  be 
vaccinated. 

Diphtheria  has  been  shown  to  be  frequently  spread  through 
the  agency  of  schools.1  This  fatal  disease  demands  especial 
precautions  on  the  part  of  teachers  and  others  involved  in  the 
management  of  schools,  to  prevent  its  introduction  to  these 
institutions. 

Children  should  not  be  admitted  to  school  coming  from  a 
house  where  there  is  at  the  time,  or  has  recently  been,  a  case  of 
contagious  disease,  such  as  small-pox,  diphtheria,  scarlet  fever, 
or  measles.  At  least  four  weeks  should  be  allowed  to  elapse 
after  the  termination  of  such  disease  before  a  child  from  the 
infected  house  is  re-admitted  to  the  school.  It  goes  without 
saying  that  no  child  having  itself  been  sick  with  a  contagious 
disease  should  be  admitted  to  school  until  entirely  restored  to 

1  The  Relations  of  Schools  to  Diphtheria  and  to  Similar  Diseases,  H.  B.  Baker,  Public 
Health,  vol.  vi,  p.  107. 


DISEASES   OF   SCHOOL-CHILDREN.  219 

health.  The  aforesaid  limit  of  four  weeks  is  the  briefest  period 
allowable  before  the  quarantine  of  the  infected  house  (so  far  as 
the  schools  are  concerned)  can  be  relaxed. 

When  a  case  of  contagious  disease  has  accidentally  obtained 
entrance  to  the  school,  the  pupils  should  be  dismissed  for  the 
day,  and  the  room  thoroughly  disinfected  by  means  of  sulphur, 
chlorine,  or,  what  is  better,  scrubbing  and  spraying  with  solution 
of  mercuric  chloride. 

Teachers  are  not  infrequently  guilty  of  the  grave  impru- 
dence of  sending  pupils  from  the  school  to  the  house  of  an  absent 
child  to  inquire  the  reason  of  the  latter's  non-appearance  at 
school.  It  frequently  happens  that  the  absent  child  is  sick,  and 
the  messenger  is  invited  to  the  sick-room  to  see  his  or  her  class- 
mate. There  can  be  no  room  for  doubt  that  scarlet  fever, 
diphtheria,  and  measles  have  often  been  introduced  into  schools 
in  consequence  of  such  thoughtlessness  on  the  part  of  teachers. 

In  order  to  promote  the  proper  hygienic  management  of 
schools,  all  teachers  should  be  required  to  submit  to  an  exami- 
nation in  the  principles  and  practice  of  hygiene,  at  least  so  far 
as  school  hygiene  especially  is  concerned.  This  is  a  demand 
that  school-boards  could  reasonably  insist  upon,  and  there  can 
be  no  question  that  the  improvement  in  the  health  of  the  pupils 
would  amply  justify  the  innovation. 

[Students  may  consult  with  advantage  the  following  special 

articles : — 

D.  F.  Lincoln,  School  Hygiene,  in  Buck's  Hygiene  and  Public 
Health,  vol.  ii,  and  Lomb  Prize  Essay  on  School  Hygiene,  Concord, 
N.  H.,  1887. — F.  Erismann,  Die  Hygiene  der  Schule,  in  Von  Pettenkofer 
und  Ziemssen's  Handb.  d.  Hygiene,  II,  Th.  2  Abth. — Reuss,  Schulbank- 
frage,  in  Realencyclopsedie  d.  ges.  Heilk.,  Bd.  XII. — H.  Colin,  Schul- 
kiuderaugen,  ibid. — C.  J.  Lundy,  School  Hygiene,  Public  Health,  vol. 
ix. — Rohe,  The  Necessity  of  the  Sanitary  Supervision  of  Schools,  Journ. 
Am.  Med.  Ass'n,  Dec.  28,  1889. — Report  of  the  Committee  on  School 
Hygiene  to  the  American  Medical  Association,  1893.] 


QUESTIONS   TO    CHAPTER   VIII. 

SCHOOLS. 

What  does  the  hygiene  of  schools  comprise?  What  principles  are 
applicable  in  the  construction  of  school-houses  ?  What  is  to  be  sought, 
and  what  avoided,  in  the  selection  of  a  site  ? 

What  should  be  the  limit  of  height  for  school-houses  ?  What  rooms 
are  needed  besides  those  for  study  or  recitation  ?  What  precautions  must 
be  observed  regarding  stairs,  railings,  and  doorways  ?  How  may  the 
ground-air  be  kept  out  of  the  building?  What  kind  of  floors  should  the 
various  rooms  have  ? 

What  will  be  probably  the  best  means  of  heating  a  school-house? 
What  is  the  usual  method  in  large  schools  ?  Which  will  usualh'  give 
the  best  ventilation,  natural  or  artificial?  When  and  how  may  school- 
rooms be  ventilated  to  advantage  ? 

How  large  should  an  ordinary  school-room  be?  What  are  the 
advantages  of  a  room  of  this  size  ?  How  many  pupils  would  this 
accommodate,  and  about  how  much  air-space  would  each  have  ?  Is  this 
sufficient? 

On  which  side  of  the  room  should  the  windows  be,  if  possible? 
How  should  the  seats  and  desks  be  arranged  in  relation  to  the  windows  ? 
What  should  be  the  relation  of  window-area  to  floor-area?  How  high 
should  the  windows  be  above  the  floor,  and  how  near  to  the  ceiling 
should  they  reach  ?  What  are  the  objections  to  windows  on  two  sides 
of  the  room  ?  Will  windows  of  the  above  dimensions  properly  illu- 
minate the  room  ?  How  much  artificial  light  will  be  needed  for  proper 
illumination?  What  should  be  the  color  of  walls  and  ceilings? 

Where  should  the  water-closets,  etc.,  of  a  school  be  located?  What 
supervision  of  these  must  be  exercised  ? 

How  high  should  school-seats  be?  What  should  be  the  relation  of 
seat  to  desk,  and  how  high  should  the  latter  be  ?  Why  should  the  front 
edge  of  the  seat  be  brought  under  the  desk  ? 

How  far  should  the  black-boards  be  from  the  pupils  ?  On  which  side 
of  the  room  ?  How  should  the  surface  be  finished? 

When  should  a  child  begin  to  go  to  school  ?  What  is  the  maximum 
time  advisable  for  daily  study  at  the  respective  ages?  What  should  be 
the  length  of  lessons  and  recitations  for  each  age  ?  What  is  an  almost 

(220) 


QUESTIONS   TO   CHAPTER   VIII.  221 

certain  result  of  too  long  study-hours  ?  Should  there  be  more  than  one 
session  daily,  and  should  recesses  be  abolished  ?  What  should  form 
part  of  the  daily  school-routine  ?  Should  this  be  taken  from  the  recess 
period,  or  should  it  be  part  of  the  school-work  ? 

What  are  some  of  the  diseases  incident  to  school-life  ?  Can  these 
be  prevented  ?  Are  they  altogether  due  to  school-life  ?  How  does  the 
proportion  of  cases  of  near-sightedness  vary  in  school-children  ?  Is  the 
increase  one  of  degree  or  of  frequency  ?  What  are  the  causes  of  this 
excess  of  myopia  ?  If  these  causes  are  avoided  or  corrected,  will  the 
prevalence  of  myopia  decrease? 

What  other  sense  is  defective  among  school-children?  What 
physical  deformity  is  very  prevalent  ?  What  are  the  special  causes  of 
this  deformity?  Why  is  it  apt  to  be  more  common  among  girls?  At 
what  age  is  the  deformity  most  apt  to  begin  ? 

What  nervous  disorders  are  frequent  among  school-children?  What 
are  some  of  the  causes  of  chronic  headache  ?  What  pupils  are  most 
subject  to  hysterical  affections?  What  are  some  causes  of  nervous 
disorders  ?  Of  digestive  disturbances  ? 

How  may  consumption  or  other  forms  of  tuberculosis  be  due  to  the 
school-life?  What  precautions  should  be  observed  in  regard  to  the  pre- 
vention of  the  spread  of  infectious  diseases  among  school-children  ? 
What  diseases  are  to  be  especially  guarded  against,  and  how  shall  this 
be  done?  What  should  be  the  shortest  limit  of  quarantine  against  a 
pupil  that  has  had  any  one  of  these  diseases?  If  a  case  of  infectious 
disease  gains  entrance  to  the  school,  what  is  to  be  done  ?  Why  should 
teachers  be  required  to  pass  an  examination  on  the  principles  of  h}rgiene  ? 


CHAPTER  IX. 

INDUSTRIAL  HYGIENE. 

ONE  of  the  most  interesting  chapters  in  the  study  of  hygiene 
is  that  which  treats  of  the  relations  of  occupations  to  health  and 
life.  While  it  is  unquestionable  that  certain  occupations  are 
intrinsically  dangerous  to  health,  there  can  be  no  doubt  that  in 
many  instances  incidental  conditions  not  necessarily  connected 
with  the  occupation  are  factors  in  the  production  of  disease. 
Such  factors  are  bad  ventilation  and  other  insanitary  surround- 
ings, as  well  as  in  many  cases  want  of  sufficient  or  proper 
food. 

Occupations  induce  disease  by  compelling  the  workmen  to 
inhale  irritating,  poisonous,  or  offensive  gases,  vapors,  or  dust ; 
or  by  causing  the  absorption  through  the  skin  or  mucous  mem- 
branes of  irritating  or  poisonous  substances.  Changes  of  tem- 
perature, as  exposure  to  great  heat  or  cold,  produce  diseases 
which  are,  in  some  instances,  characteristic.  In  another  class 
of  cases  the  excessive  use  of  certain  organs,  as  the  nervous 
system,  the  eyes,  the  vocal  organs,  or  various  groups  of  muscles, 
produce  characteristic  morbid  effects.  Again,  a  constrained 
attitude  while  at  work,  a  sedentary  life,  or  occupations  involving 
exposure  to  mechanical  violence  are  recognized  sources  of  dis- 
ease and  death. 

The  following  table  gives  the  mortality  and  average  age  at 
death  of  all  decedents  over  20  years  of  age  whose  occupation 
was  specified,  in  the  State  of  Massachusetts,  for  thirty-one 
years  and  eight  months.  The  total  number  of  decedents  was 
144,954;  the  average  age  at  death,  50.90  years.  Subdivided 
into  classes  and  individual  occupations,  the  results  are  as 
follow : — 

(223) 


224 


TEXT-BOOK   OF   HYGIENE. 


TABLE  XX. 

Occupations  of  Persons  whose  Occupations  were  specified,  and  whose  Deaths  were 
registered  in  Massachusetts  during  a  period  of  thirty -one  years  and  eight 
months,  ending  with  December  31,  1874. 1 


OCCUPATIONS. 

Number 
of 
Persons. 

Average 
Age  at 
Death. 

OCCUPATIONS. 

Number 
of 
Persons. 

Average 
Ape  at 
Death. 

CLASS  I.    Cultivators  of 
the  Earth:  Farmers, 
Gardeners  etc 

31  832 

65  29 

Nail-makers     .... 
Pail-  and  Tub-  makers 
Painters        ... 

174 

5 
1  850 

41.49 
36.60 
45  07 

CLASS  II.     Active  Me- 
chanics Abroad  . 

10,893 

56  19 

Paper-makers  .... 
Piano-forte-makers    . 
Plumbers  ...       .    . 

288 
111 
131 

48.29 
43.33 
3553 

Brick-makers     .... 
Carpenters  and  Joiners 
Caulkers  and  Gravers 

106 
6,150 
180 

46.85 
53.33 
58  59 

Potters  
Pump-    and     Block- 
makers       

40 

89 

56.67 
54.79 

Masons        •           ... 

1  662 

50  33 

Reed-makers   . 

9 

42  78 

Millwrights    

118 

59  14 

Rope-makers   .... 

248 

58.05 

RjcrcrfM-g      . 

161 

52  25 

Tallow-chandlers  .    . 

67 

54.93 

Ship-carpenters     .   .   . 

873 

58  53 

Tinsmiths     

375 

41  05 

Slaters  

81 

4099 

Trunk-makers     .    .   . 

48 

39.60 

Stone-cutters  

1,025 

4090  ! 

Upholsterers    .... 

124 

38.82 

Tanners 

537 

50  36 

^Veavers    

480 

44  95 

CLASS  III.    Active  Me- 
chanics in  Shops  .    . 
Bakers  

16,576 
471 

47.57 
47  04 

Wheelwrights     .    .    . 
Wood-turners  .... 
Mechanics  (not  speci- 
fied) 

507 
76 

2,015 

56.98 
52.07 

44.84 

Blacksmiths  

2,402 

5326 

Brewers          

28 

47  11 

CL  vss    IV.     Inactive 

Cabinet-makers    .   .   . 
Calico-printers  .... 
Card-makers  

781 
9 
39 

48.84 
52.11 
48  23 

Mechanics  in  Shops 
Barbers         
Basket-makers    .    .    . 

17,233 
403 
70 

43.87 
39.81 
61  63 

Carriage  -  makers   and 
Trimmers           .       . 

276 

48  21 

Book-binders  .... 
Brush  -makers 

150 
53 

40.12 
43  11 

Chair-makers     .... 
Clothiers               ... 

138 
84 

41.77 
56  50 

Carvers             .... 
Ci^ar-makers 

90 
154 

34.00 
38  36 

Confectioners    .... 
Cooks      .   .       .... 

85 
112 

44.11 

40  82 

Clock  -    and    watch- 
makers ... 

100 

5286 

Coopers  

927 

59  22 

Comb-makers         .    . 

134 

51  38 

Coppersmiths    .... 

101 

4589 

Engravers     

124 

40.88 

Curriers  

366 

41.50 

Glass-cutters    .... 

76 

43.16 

Cutlers     

131 

39  21 

Harness-makers  •    .    • 

423 

48.74 

Distillers     

27 

56  85 

Jewelers               .    . 

468 

40  34 

Dyers  

143 

45  17 

2,138 

39.16 

Founders    .... 

361 

42  51 

Printers         •    • 

717 

38  62 

Furnace-men    .... 

133 

4342 

Sail-makers  .           .    . 

217 

5321 

Glass-blowers   .... 
Gunsmiths     

132 
250 

37.88 
48  86 

Shoe-cutters     .... 
Shoe-makers           .    . 

362 

9,772 

42.94 
44  61 

Hatters    

356 

5467 

Silver  or  Gold  smiths 

92 

46.13 

Leather-dressers 

179 

47  23 

Tailors   .                ... 

1,393 

47  34 

Machinists      

2,097 

41  67 

Tobacconists    .... 

43 

50.35 

Millers     

278 

57  14 

Whip-makers  .... 

99 

42.63 

Musical-Inst.  mkrs.     . 

33 

46.73 

Wool  -sorters    .... 

155 

48.09 

1  Thirty-third  Registration  Report  of  Massachusetts,  p.  cvi  et  seq. 


INDUSTRIAL    HYGIENE. 


225 


TABLE  XX  (continued). 


OCCUPATIONS. 

Number 
of 
Persons. 

Average 
Age  at 
Death. 

OCCUPATIONS. 

Number 
of 
Persons. 

Average 

Age  at 
Death  . 

CLASS  V.  Laborers  (no 
special  trades)  .    .    . 
Laborers      .    . 

28,058 
27,382 
389 
76 
193 

18 

7,035 
37 
246 
537 
4 
327 
17 
567 
216 
9 
10 
417 
81 
2,885 
354 
1,282 
24 
22 

8,844 
433 
4 
58 
82 
8,267 

15,977 
376 
49 
151 
75 
73 
198 
3,435 

255 

47.41 
47.49 
40.10 
52.09 
5006 

39.67 

36.29 
34.08 
26.44 
50.19 
34.50 
38.88 
49.29 
38.77 
41.30 
53.78 
60.40 
45.18 
5994 
2837 
42.54 
40.35 
60.67 
50.00 

46.44 
42.82 
41.25 
50.00 
60.38 
46.45 

48.95 
46.76 
57.61 
55.14 
47.96 
53  05 
49.58 
35.93 

42.37 

Gentlemen          .   .    . 

1,512 
517 
467 
1,375 
3,927 
27 

318 

299 

12 
5 
2,908 

5,175 
29 
186 
117 
965 
32 
114 
87 
18 
676 
266 
10 
1,166 
45 
437 

158 
288 
86 
495 

3,343 
1,037 
259 
136 
116 
703 
289 
48 
73 
233 
442 
7 

68.42 
47.59 
50.04 
51.23 
54.17 
41.22 

39.85 

40.90 
45.25 
28.80 
48.08 

50.81 
47.07 
44.18 
42.32 
58.57 
3731 
41.61 
46.68 
64.11 
56.45 
41.59 
36.80 
54.99 
55.93 
55.37 

53.76 
23.23 
51.44 
41.79 

39.13 
46.64 
43.36 
39.42 
61.06 
27.82 
46.50 
43.12 
3483 
47.49 
31.27 
24.43 

Grocers             .       .    . 

Innkeepers   . 

Servants  

Manufacturers    .   .    . 
Merchants    .    . 
News-dlrs.  and  Car'rs 
R.  R.  Agents  or  Con- 
ductors     .... 
Saloon-    and  Restau- 
rant- keepers   .    .    . 
Stove-dealers   .... 
Telegraphers   .... 

Stevedores  

Watchmen             .    .    . 

Workmen  in  Powder- 
mills     

CLASS    V  I  .      Factors 
Laboring  Abroad,  etc. 
Baggage-masters  .    .    . 
Brakemen       

Butchers                .    .    . 

CLASS    IX  .      Profes- 
sional Men    .... 
Architects     

Chimney-sweeps  .    .    . 
Drivers    

Engin'rs  and  Firemen 
Expressmen  .           .    . 

Artists    

Civil  Engineers  .    .    . 
Clergymen   

Lighthouse-keepers 

Comedians    .       ... 

Dentists     

Sextons    

Editors  and  Reprtrs. 
Judges  and  Justices  . 
Lawyers    

Soldiers    

Stablers 

Teamsters  .    .    . 

Musicians     
Photographers    .    .    . 
Physicians 

Weighers  and  Gaugers 
Wharfingers  

CLASS  VII.     Employed 
on  the  Ocean  .... 
Fishermen  .... 

Professors     .   .       .    . 

Public  Officers     .    .    . 
Sheriffs,    Constables, 
and  Policemen    .    . 
Students    .    .    . 

Marines   

Naval  Officers   .... 
Pilots    .    .           .... 

Surveyors     

Teachers 

Seamen    

CLASS  X.     Females  . 
Domestics     

CLASS  VIII.    Merch'ts, 
Mnanc'rs,  Ag'ts,  etc. 
Agents     

Dress-makers  .... 
Milliners   

Bankers  

Nurses   .               ... 

Bank  Officers     .... 
Boarding-House  kprs. 
Book-sellers              .    . 

Operatives    .    .       .    . 

Seamstresses    .... 
Shoe-binders    .... 
Straw-workers     .    .    • 
Tailoresses    

Brokers        ... 

Clerks  and  Book-kprs. 
Druggists  and  Apoth- 
ecaries       

Teachers           .... 

Telegraphers    .... 

The  above  table  cannot  be  absolutely  relied  upon  for  several 
reasons,  the  principal  of  which  is  that  the  table  is  incomplete. 
Many  of  the  occupations  are  merely  temporary,  and  persons  are 


226  TEXT-BOOK    OF    HYGIENE. 

constantly  shifting  from  the  pursuit  of  one  calling  to  another 
Judges  and  lawyers,  for  example,  should  be  included  under  one 
heading,  while  the  class  "  students  "  should  be  excluded  alto- 
gether. The  table  shows,  however,  very  clearly,  the  relations  of 
certain  occupations  to  longevity.  It  is  seen,  for  example,  that 
agriculturists  have  the  greatest  expectation  of  life.  Next  to 
these  come  mechanics  engaged  out-of-doors.  Professional  men 
come  next,  and  of  these  clergymen  and  members  of  the  bar  have 
the  first  and  second  places,  respectively.  The  expectation  of 
life  of  physicians  is  above  the  average,  being  nearly  55  years. 
Mechanics  engaged  in  active  work  in-doors  may  expect  to  live 
3.70  years  longer  than  those  whose  occupation  requires  them  to 
retain  a  more  or  less  constant  position. 

Occupations  which  are  accompanied  by  the  formation  of 
much  dust,  either  inorganic  or  organic,  are  especially  unfavor- 
able. They  usually  produce  diseases  of  the  respiratory  organs, 
which  may  eventuate  in  phthisis.  In  the  table  it  is  seen 
that  the  average  age  at  death  of  stone-cutters  was  40.90 ;  of 
cotton-factory  operatives — male  39.16,  female  27.82  ; l  of  cigar- 
makers,  38.36 ;  and  of  cutlers,  39.21  years.  The  figures  more 
or  less  closely  approximate  the  conditions  which  have  been 
shown  to  exist  in  England  and  on  the  Continent  of  Europe.  In 
Sheffield,  the  workmen  who  grind  and  polish  the  cutlery,  called 
"  dry  grinders,"  are  said  to  suffer  from  a  characteristic  pulmo- 
nary affection  termed  "grinders'  asthma"  (emphysema)  in  the 
proportion  of  69  per  cent,  of  the  whole  number  employed.  The 
average  duration  of  life  of  the  needle-grinders  of  Derbyshire 
is  30.66  years.  Among  the  cutlery-grinders  of  Solingen,  in 
Hhenish  Prussia,  Oldendorff  found  29  per  cent,  suffering  from 
pulmonary  affections,  while  the  average  age  at  death  of  the 
"  dry  grinders  *'  was  40.7  years. 

1  These  figures  must  be  accepted  with  much  reserve.  While  it  is  probable  that  the 
average  age  at  death  among  women  engaged  in  different  occupations  is  less  than  that  of  men 
engaged  in  the  same  occupations,  the  figures  in  Table  XX,  Class  X,  cannot  be  used  as  a  basis  of 
comparison.  So  many  women  arc  annually  withdrawn  from  the  various  occupations  by  mar 
riage,  which  places  them  under  different  conditions,  that  the  statistics  of  the  occupations  of 
women  in  the  table  are  untrustworthy. 


OCCUPATIONS   PREJUDICIAL   TO    HEALTH.  227 

OCCUPATIONS   PREJUDICIAL   TO   HEALTH. 

The  diseases  of  occupations  may  conveniently  be  divided 
into  the  following  classes : — 

1.  Diseases  due  to  the  inhalation  of  irritating  or  poisonous 
gases  and  vapors. 

2.  Diseases  due  to  the  inhalation  of  irritating  or  poisonous 
dust. 

3.  Diseases  due  to  the  absorption  or  local  action  of  irritating 
or  poisonous  substances. 

4.  Diseases  due  to  exposure  to  elevated  or  variable  temper- 
ature or  atmospheric  pressure. 

5.  Diseases  due  to  excessive  use  of  certain  organs. 

6.  Diseases  due  to  a  constrained  attitude  and  sedentary  life. 

7.  Diseases  from  exposure  to  mechanical  violence. 

I. DISEASES  DUE  TO  THE  INHALATION  OF  IRRITATING  OR  POISONOUS 

GASES   OR   VAPORS. 

Sulphurous-acid  gas  is  used  in  various  trades'  as  a  bleach- 
ing agent.  In  the  manufacture  of  straw  hats  and  in  the  drying 
or  "  processing  "  of  hops  this  agent  is  extensively  employed, 
and  the  people  engaged  in  these  industries  frequently  suffer 
from  respiratory  and  digestive  disorders.  These  are,  however, 
rarely  serious.  If  free  access  of  air  is  allowed,  the  dangers  to 
health  in  the  above  employments  are  very  slight. 

Nitric-acid  fumes  may  be  dangerous  to  health  when  in- 
haled in  a  concentrated  form,  but  very  few  cases  are  on  record 
where  any  positively  deleterious  influence  can  be  traced  to  this 
agent. 

Hydrochloric-acid  fames  may  prove  deleterious  to  the  work- 
men in  soda  manufactories,  where  the  fumes  are  disengaged 
during  the  so-called  "  sulphate  process."  But  the  danger  is 
probably  slight.  On  the  other  hand,  attention  has  recently  been 
called  to  a  peculiar  effect  of  hydrochloric-acid  fumes  upon  the 
workmen  in  fruit-canning  establishments.  The  men  who  seal 
or  "  cap  "  the  cans  after  being  filled  are  the  ones  affected.  The 


228  TEXT-BOOK.  OF   HYGIENE. 

lesion  has  been  described  by  Dr.  W.  Stump  Forwood,  who  says 
concerning  it :  "  The  constant  inhalation  of  the  fumes  of  muri- 
atic acid,  associated  as  they  are  with  the  lead  solder,  which  the 
busy  "  capper "  neglects  to  protect  himself  against,  soon  pro- 
duces inflammation  of  the  mucous  membrane  of  the  nose,  which 
finally  results  in  ulceration.  With  some  patients,  after  the 
removal  of  the  cause  and  the  application  of  proper  treatment, 
recovery  takes  place  after  two  or  three  months ;  but  with  those 
who  have  a  scrofulous  taint  in  their  constitutions  this  ulceration 
is  exceedingly  intractable,  and,  in  spite  of  all  treatment,  proceeds 
for  months  and  even  years,  until  the  septum  is  finally  perforated. 
And,  strange  to  say,  it  is  the  common  experience  of  those  who 
have  suffered  that,  as  soon  as  perforation  takes  place,  all  the 
soreness  and  consequent  annoyance  disappears  and  the  patient 
recovers,  with,  of  course,  a  permanent  opening  in  the  nasal 
septum." l  Dr.  Forwood  adds  that  anointing  the  nose,  both 
within  and  without,  several  times  a  day,  and  avoidance  of  the 
acid  fumes  as  much  as  possible,  will  prevent  the  peculiar  affection. 

Ammonia  rarely  causes  disturbances  of  health  in  work- 
men brought  into  contact  with  it.  AVhen  present  in  the  air  in 
large*  proportion  it  may  give  rise  to  serious  symptoms.  As  it  is 
often  used  to  prevent  the  poisonous  effects  of  mercury  (q.  v.),  care 
should  be  taken  that  the  proportion  of  the  vapor  in  the  air  of 
the  work-room  should  not  exceed  5  per  cent. 

Chlorine  gas  is  very  deleterious  in  its  effects  upon  the  work- 
men brought  in  contact  with  it  in  the  various  industries  in  which 
it  is  employed.  Nearly  one-half  of  the  workmen  engaged  in  the 
manufacture  of  chlorinated  lime  and  in  bleaching  become  affected. 

The  respiratory  organs  are  principally  attacked.  Pneu- 
monia is  exceptionally  frequent.  If  an  affected  individual  is 
predisposed  to  consumption  the  latter  disease  is  soon  lighted  up, 
and  quickly  proves  fatal.  The  effect  of  the  inhalation  of  con- 
centrated chlorine  is  thus  graphically  described  by  Hirt 2 :  "  The 

iPhila.  Med.  and  Surgical  Reporter,  June  30,  1883. 

*  Von  Pettenkofer  und  Ziemssen's  Handbuehder  Hygiene,  etc.,  II  Th.,  4  Abth.,  p.  30. 


DISEASES   DUE   TO   INHALATION    OF   GASES   OR   VAPORS.       229 

workman  suffers  from  violent  cough  and  extreme  dyspnoea.  In 
spite  of  the  aid  of  the  auxiliary  respiratory  muscles,  the  entrance 
of  air  to  the  lungs  is  insufficient,  and  the  widely-opened  eyes, 
the  pale-bluish  color,  and  the  cold  perspiration  plainly  show  the 
mortal  agony  of  the  patient.  With  this  the  pulse  is  small,  the 
temperature  decreased.  Soon  after  removal  from  the  impreg- 
nated atmosphere  these  phenomena  disappear,  and  a  few  hours 
later  the  workman  is  found  enveloped  in  chlorine  and  hydro- 
chloric-acid vapors  in  his  accustomed  place  in  the  factory.  The 
attacks  seem  to  be  but  rarely  fatal." 

The  constant  inhalation  of  an  atmosphere  strongly  impreg- 
nated with  chlorine  produces  a  cachectic  appearance,  bronchial 
catarrh,  loss  of  the  sense  of  smell,  and  a  prematurely  aged  appear- 
ance. When  this  stage  of  chronic  chlorine  poisoning  has  been 
reached  complete  health  can  rarely  be  re-established,  even  if 
the  patients  be  entirely  removed  from  the  irritating  atmosphere. 

Carbon  monoxide  is  often  present  in  the  air  of  gas-works, 
iron  smelting-works,  and  coke  or  charcoal  furnaces.  The  work- 
men engaged  in  these  industries  often  suffer  with  diseases  of  the 
respiratory  organs,  digestive  disturbances,  and  general  debility. 
Acute  poisoning  from  carbon  monoxide  is  relatively  frequent,  as 
already  pointed  out.1  The  prominent  symptoms  are  at  first  vio- 
lent headache,  dizziness,  and  roaring  in  the  ears.  These  symp- 
toms are  followed  by  great  depression  of  muscular  power,  nausea, 
and  vomiting.  The  vomited  matters  sometimes  gain  entrance 
into  the  trachea,  and  may  thus  produce  strangulation.  Uncon- 
sciousness, convulsions,  and  asphyxia  rapidly  succeed.  Paral- 
yses of  the  sphincters  and  of  groups  of  other  muscles  are  often 
present.  The  pulse  is  at  first  somewhat  increased,  but  soon 
becomes  slower.  The  respiration  is  slow  and  stertorous,  and  tho 
temperature  falls  from  2.5°  to  3°  C.  (3°  to  4°  F.).  Glycosuria 
often  occurs.  If  death  does  not  occur  in  the  attack,  the  patient  fre- 
quently suffers  from  great  depression,  both  physical  and  mental; 
loss  of  appetite,  constipation,  and  various  paretic  conditions. 

1  See  Chapter  I,  p.  29. 


230  TEXT-BOOK   OF   HYGIENE. 

The  slow  or  chronic  form  of  poisoning  by  carbon  monoxide 
is  characterized  by  headache,  dizziness,  slow  pulse  and  respira- 
tion, nausea,  and  sometimes  vomiting  and  purging.  Loss  of 
memory  and  diminution  of  mental  activity  are  also  said  to  be 
effects  of  the  continued  inhalation  of  air  charged  with  carbon 
monoxide. 

Carbon  dioxide  is  found  as  one  of  the  constituents  of  the 
"choke-damp"  in  mines.  There  is  reason  to  believe  that  this 
is  often  the  source  of  ill  health  and  death  in  miners,  even  where 
the  symptoms  of  acute  carbon-dioxide  poisoning  are  not  present. 
Hon.  Andrew  Roy1  says  that  "it  is  more  insidious  than  direct  in 
its  operations,  gradually  undermining  the  constitution  and  kill- 
ing the  men  by  inches."  Difficulty  of  respiration  and  weakness 
are  the  only  symptoms  calling  attention  to  the  pernicious  effects 
of  the  gas.  Where,  however,  the  proportion  of  carbon  dioxide 
is  large,  acute  poisoning  occurs.  This  is  manifested  by  the 
following  symptoms :  Loss  of  consciousness  and  of  the  power  of 
voluntary  motion.  In  some  cases  there  are  convulsions ;  in 
others  the  above  symptoms  are  preceded  by  difficult  respiration, 
headache,  depression,  drowsiness,  or  psychical  excitement.  Re- 
covery usually  soon  follows  after  removing  the  patient  into  a 
purer  atmosphere. 

Vintners,  distillers,  brewers,  and  yeast-makers  are  said  to 
suffer  from  the  effects  of  carbon  dioxide  occasionally,  but  serious 
results  from  this  cause  are  probably  very  infrequent. 

It  may  not  be  amiss  to  call  attention  here  to  another  dan- 
gerous mixture  of  gases  sometimes  found  in  mines,  and  which 
is  occasionally  the  source  of  appalling  accidents.  This  is  the 
so-called  "fire-damp"  or  light  carburetted  hydrogen  (CH4). 
When  this  gas  is  mixed  with  atmospheric  air  in  the  proportion 
of  6  to  10  volumes  per  cent,  the  mixture  becomes  violently 
explosive  if  ignited.  The  danger  does  not  cease  with  the  explo- 
sion, however,  for  in  this  act  the  free  oxygen  present  is  consumed 

1  Third  Annual  Report  State  Mine  Inspector  of  Ohio.  Quoted  in  Buck's  Hygiene  and 
Public  Health,  vol.  ii,  p.  243. 


DISEASES   DUE   TO    INHALATION    OF   GASES   OR   VAPORS.       231 

in  the  formation  of  carbon  dioxide,  and  the  workmen  then  die 
asphyxiated,  or  from  the  effects  of  "choke-damp."  The  dangers 
from  "fire-damp"  can  be  largely  averted  by  thorough  ventilation 
and  by  the  use  of  the  safety-lamp  of  Sir  Humphry  Davy,  which 
gives  warning  of  the  presence  of  the  gas  and  permits  the  work- 
men to  escape  before  the  explosion  takes  place. 

Sulphuretted  hydrogen,  when  present  in  the  air  in  large 
proportion, — as,  for  example,  in  privy-vaults,  cess-pools,  and 
sewers, — may  produce  serious  or  fatal  poisoning.  Formerly, 
when  vaults  were  cleaned  in  the  primitive  way,  these  accidents 
were  frequent;  but  at  the  present  day,  owing  to  improved 
methods  of  removing  excreta,  they  are  comparatively  rare.  The 
precautions  advised  in  a  preceding  chapter1  should  be  borne  in 
mind  when  it  is  necessary  for  workmen  to  enter  such  places. 

The  gases  resulting  from  the  putrid  decomposition  of  organic 
substances,  such  as  are  found  in  tanneries,  glue-  and  soap-  works, 
and  similar,  industries,  are  popularly  believed  to  give  rise  to 
various  diseases.  There  are  no  observations  on  record,  however, 
to  show  that  such  is  the  case.  As  a  matter  of  fact,  the  workmen 
engaged  in  the  industries  mentioned,  seem  to  be  exceptionally 
healthy,  and  to  resist  to  a  considerable  degree  the  ravages  of 
phthisis  and  epidemic  diseases. 

Bisulphide  of  carbon  is  used  in  the  arts  principally  in  the 
process  of  vulcanizing  India  rubber,  and  for  extracting  oils  from 
seeds  and  fatty  bodies.  The  constant  inhalation  of  the  vapor 
of  bisulphide  of  carbon  produces  a  train  of  symptoms  to  which 
attention  was  first  attracted  by  Delpech  in  1856.  The  symp- 
toms have  been  observed  frequently  since  that  time.  The  follow- 
ing account  is  from  Hirt2: — 

"  Some  days,  or  even  weeks  or  months,  after  beginning  this 
occupation,  the  workmen  complain  of  a  dull  headache,  becoming 
more  severe  toward  evening.  This  symptom  is  soon  followed  by 
joint-pains,  formication,  and  itching  on  various  parts  of  the  body. 
A  more  or  less  troublesome  cough  is  present,  but  is  not  accom- 

1  Chapter  I,  p.  37.  *  Op.  cit.,  p.  66. 


232  TEXT-BOOK   OF   HYGIENE. 

panied  by  any  characteristic  sputa.  The  respiration  is  regular, 
the  pulse  somewhat  increased  in  frequency.  During  this  time 
certain  individuals  exhibit  a  marked  exaltation  of  their  intel- 
lectual powers;  they  talk  more  than  formerly,  and  show  an 
interest  in  matters  in  which  they  at  other  times  show  no  concern. 
There  is,  however,  very  rarely  distinct  mental  disease.  The 
sexual  desires  are  increased  in  both  sexes,  menstruation  becomes 
irregular,  and  the  urine  possesses  a  faint  odor  of  bisulphide  of 
carbon.  In  this  manner  several  weeks  or  months  pass  away. 
Very  gradually  the  psychical  exaltation  disappears,  and  a  pro- 
found depression,  melancholy,  and  discouragement  succeeds, 
coupled  with  which  is  often  loss  of  memory.  Vision  and  hear- 
ing become  less  acute,  and  the  sexual  activity  is  completely 
destroyed.  Anaesthetic  spots  appear  on  various  parts  of  the  body, 
and  numbness  of  the  fingers  prevents  the  workman  from  perform- 
ing any  fine  work." 

The  disease  never  proves  fatal,  but  the  normal  condition 
of  the  individual  is  rarely  re-established  when  the  disorder  has 
advanced  to  the  extreme  stages  mentioned. 

Iodine  and  bromine  vapors,  when  inhaled  by  workmen  en- 
gaged in  their  preparation,  produce  symptoms  of  poisoning 
which  are  sometimes  very  serious.  Acute  iodic  intoxication 
consists  in  severe  laryngeal  irritation,  headache,  conjunctivitis, 
and  nasal  catarrh.  Occasionally  there  is  temporary  loss  of  con- 
sciousness. Chronic  iodic  cachexia  is  often  found  among  the 
workmen.  In  certain  cases  atrophy  of  the  testicles  and  gradual 
disappearance  of  sexual  power  has  been  observed.  In  the  manu- 
facture of  bromine,  a  form  of  bronchial  asthma  has  been 
observed  among  those  engaged  in  the  establishment.  No 
symptoms  corresponding  to  those  of  chronic  iodism  have  been 
observed  among  the  workmen  in  bromine. 

The  inhalation  of  the  vapors  of  turpentine  produces,  in  a 
considerable  number  of  those  constantly  exposed  to  them,  dis- 
eases of  the  respiratory  organs,  beginning  with  cough  and,  at 
times,  resulting  in  consumption.  In  other  cases  derangement 


DISEASES    DUE   TO   INHALATION    OF   GASES   OR   VAPORS.       233 

of  the  digestive  organs,  strangury,  and,  in  a  few  cases,  bloody 
urine  have  been  observed.  Nervous  disturbances  are  rare  after 
the  inhalation  of  turpentine,  and  are  limited  to  headache,  roar- 
ing in  the  ears,  or  flashes  of  light  before  the  eyes. 

Petroleum  vapor,  when  inhaled  in  a  concentrated  state,  pro- 
duces symptoms  similar  to  those  of  anaesthetics.  When  exposed 
for  a  long  time  to  diluted  petroleum  vapor,  workmen  sometimes 
suffer  from  chronic  pulmonary  catarrhs  or  from  nervous  de- 
rangements. Among  the  latter  are  disturbances  of  mental 
activity,  loss  of  memory,  giddiness,  and  headache.  These  symp- 
toms are,  however,  rare.  More  frequent  are  pustular  or  furuncu- 
lar  affections  of  the  skin,  which  are  due  probably  to  the  direct 
irritant  effect  of  the  vapor. 

Lead  poisoning  is  one  of  the  most  characteristic  diseases  of 
artisans.  It  attacks  workmen  engaged  in  the  roasting  and  smelt- 
ing of  lead  ores ;  in  the  manufacture  of  white  and  red  lead  and 
of  lead  acetate  and  chromate ;  in  type-making,  in  painting,  and, 
in  short,  in  all  occupations  in  which  the  workman  is  compelled 
to  inhale  the  vapor  or  dust  of  lead,  or  in  which  it  is  conveyed 
in  some  manner  to  the  digestive  organs.  It  is  believed  also  that 
it  can  be  absorbed  by  the  skin  and  produce  its  poisonous  effects 
upon  the  economy.  The  average  duration  of  life  in  the  roast- 
ing and  smelting  furnaces  is  41  years ;  of  painters,  as  shown  by 
Table  XX,  45.07  years.  Of  the  latter  75  per  cent,  are  attacked 
by  one  of  the  forms  of  lead  poisoning,  colic  being  most  frequent. 
In  the  manufacture  of  white  lead  more  than  half  of  the  work- 
men suffer  from  lead  poisoning  during  the  first  year,  lead  colic 
being  present  in  60  per  cent,  of  all  the  cases. 

In  most  sugar-of-lead  manufactories  60  per  cent,  of  all 
the  operatives  constantly  suffer  from  some  form  of  lead 
poisoning. 

Poisoning  has  also  been  observed  in  workmen  engaged  in 
the  manufacture  of  various  pigments  of  which  the  acetate  of 
lead  is  the  base  (e.g.,  lead  chromates).  Among  type-founders 
the  symptoms  of  lead  poisoning  are  not  very  rare,  and  even 


23-t  TEXT-BOOK   OF   HYGIENE. 

compositors  sometimes  suffer  from  lead  poisoning.  In  the  latter 
case  the  lead  must  be  absorbed  through  the  skin  in  order  to 
produce  its  effects. 

The  various  forms  in  which  lead  poisoning  affects  the  indi- 
vidual are  the  lead  cachexia,  manifested  by  loss  of  weight,  dis- 
coloration of  the  skin,  the  characteristic  blue  line  along  the 
gums,  diminution  of  the  salivary  secretion,  a  sweetish  taste,  and 
offensive  odor  of  the  breath ;  then  lead  colic,  the  features  of 
which  are  well  known  ;  lead  paralysis,  the  characteristic  "  wrist- 
drop,"  which  requires  prompt  and  intelligent  treatment,  other- 
wise permanent  atrophy  of  the  affected  muscles  often  takes  place. 
Among  other  nervous  manifestations  of  the  poison  is  a  painful 
affection  of  the  lower  extremities,  attacking  joints  and  flexor 
muscles,  and  remittent  in  character.  At  times  anaesthesia  of  the 
skin  of  the  head  and  neck  is  present.  In  rare  cases  serious 
mental  derangement  occurs.  Other  grave  nervous  lesions,  such 
as  the  so-called  saturnine  hemiplegia  and  tabes,  are  happily 
extremely  rare  among  the  workmen  in  the  metal  at  the  present 
day. 

Mercurial  poisoning  is  frequent  among  the  artisans  who 
work  in  the  metal.  The  smelters  of  the  ore  suffer  severely  and 
in  a  large  proportion  of  the  entire  number  employed.  Their 
average  age  at  death  is  45  years.  Mirror-makers  suffer  most 
severely  of  all  the  artisans  who  come  in  contact  with  the  vapors 
of  the  metal.  It  is  beyond  question  that  the  confinement  in 
badly-ventilated  work-rooms  is  largely  responsible  for  the  poi- 
sonous effects  of  the  metal  upon  this  class.  The  special  forms 
in  which  the  poisonous  effects  are  manifested  in  mirror-makers 
are  salivation,  mercurial  tremor,  and  nervous  erethism,  but,  in 
addition,  a  very  large  proportion  surfer  from  pulmonary  con- 
sumption. It  is  stated  that  71  per  cent,  of  the  total  deaths 
among  mirror-makers  (those  who  coat  the  glass  with  the  mer- 
curial alloy)  are  from  phthisis. 

Among  women  the  symptoms  are  aggravated,  and  abortion 
frequently  occurs.  Of  the  children  of  women  suffering  from 


DISEASES   DUE   TO   INHALATION    OP   GASES   OR   VAPORS.       235 

mercurial  poisoning  born  living  at  term,  65  per  cent,  die  within 
the  first  year. 

In  the  Almaden  quicksilver  mines  in  Spain  a  considerable 
proportion  of  the  workmen  suffer  from  the  milder  symptoms  of 
mercurial  intoxication  (gingivitis,  salivation,  or  dryness  of  the 
mouth).  The  more  severe  manifestations  (tremor,  convulsions, 
contractures,  violent  muscular  pains,  paralysis,  cachexia)  are 
much  less  frequent,  and  latterly  not  so  severe  as  they  were 
formerly. 

Fire-gilders,  fulminate- makers,  and  physical  instrument- 
makers  not  infrequently  suffer  from  the  deleterious  effects  of 
inhaling  the  vapor  of  mercury.  Hatters  are  also  liable,  to  a 
considerable  extent,  to  the  poisonous  effects  of  the  metal.1 

It  has  been  found  that  upon  sprinkling  the  floor  of  the 
work-room  of  mirror-makers  with  aqua  ammonia,  so  as  to  im- 
pregnate the  atmosphere  with  ammonia,  the  bad  effects  of  mer- 
cury on  the  system  are  markedly  diminished.  Care  must  be 
taken,  however,  not  to  use  the  ammonia  to  excess,  otherwise  the 
diseases  caused  by  this  agent  may  attack  the  workmen. 

Zinc  or  copper  vapors,  or  possibly  a  combination  of  the 
two,  given  off  from  the  brass,  which  is  an  alloy  of  these  metals, 
produces  a  peculiar  train  of  symptoms  known  as  "brass- 
founders'  ague."  The  symptoms  are  described  by  Hirt,  who 
has  suffered  from  two  attacks  of  the  affection  himself,  as  fol- 
lows 2 :  "A  few  hours  after  attending  the  process  of  brass- 
casting,  one  notices  a  peculiar,  uncomfortable  sensation  over  the 
whole  body.  More  or  less  severe  pains  in  the  back  and  gen- 
eral lassitude  cause  a  discontinuance  of  the  ordinary  occupa- 
tion. While  the  pains  appear  now  here,  now  there,  and  are 
extremely  annoying,  no  changes  in  the  pulse  or  respiration  are 
noticeable.  In  a  short  time,  however,  usually  after  the  patient 
has  taken  to  the  bed,  chilliness  comes  on,  which  soon  increases 
to  a  decided  rigor,  lasting  fifteen  minutes  or  longer.  In  the 

i  Hatting  as  Affecting  the  Health  of  Operatives,  L.  Dennis,  Report  New  Jersey  State 
Board  of  Health,  1879 ;  Connecticut  State  Board  of  Health,  1883. 
*  Op.  cit.,  p.  122. 


236  TEXT-BOOK   OF   HYGIENE. 

course  of  an  hour  or  less  the  pulse  now  reaches  a  rapidity  of 
100  to  120  beats  per  minute.  A  tormenting  cough,  combined 
with  a  feding  of  soreness  in  the  chest,  comes  on.  In  conse- 
quence of  the  repeated  acts  of  coughing,  the  increasing  frontal 
headache  produces  exceeding  discomfort.  Soon,  however,  usu- 
ally after  a  few  hours,  the  height  of  the  attack  is  reached ;  free 
perspiration  indicates  the  stage  of  defervescence,  and  during  the 
gradual  diminution  of  the  symptoms  the  patient  falls  into  a 
deep  sleep,  lasting  several  hours.  On  awakening,  a  slight 
headache  and  lassitude  only  remain  as  reminders  of  the 
attack." 

It  is  said  that  about  75  per  cent,  of  the  workmen  in  brass- 
foundries  are  attacked  by  this  affection ;  the  attack  is  liable  to 
be  repeated  at  every  exposure. 

A  chronic  form  of  poisoning  is  said  to  occur  among  zinc- 
smelters  after  following  their  occupation  for  ten  to  twelve  years. 
It  consists  of  hyperaesthesia,  formication,  and  burning  of  the 
skin  of  the  lower  extremities,  soon  followed  by  alteration  in  the 
temperature  and  tactile  sensation,  and  diminution  of  the  mus- 
cular sense.  Paresis  of  the  lower  extremities  sometimes  comes 
on.  The  disease  has  not  yet  been  sufficiently  investigated. 

Aniline  vapor  is  exceedingly  poisonous  when  inhaled  in  a 
concentrated  state.  Hirt  describes  an  acute  form  which  usually 
results  fatally :  "  The  workman  falls  suddenly  to  the  ground ; 
the  skin  is  cold,  pale ;  the  face  is  cyanotic,  the  breath  has  the 
odor  of  aniline,  the  respiration  is  slowed,  and  the  pulse  increased. 
The  sensation,  diminished  from  the  beginning  of  the  attack, 
gradually  entirely  disappears,  and  death  follows  in  a  state  of  deep 
coma."1  There  is  a  milder  form  which  comes  on  after  several 
days  of  exposure.  It  is  characterized  by  laryngeal  irritation, 
diminution  of  appetite,  headache,  giddiness,  great  weakness, 
and  depression.  The  pulse  is  rapid,  small,  and  irregular. 
Respiration  is  little  altered.  There  is  decrease  of  sensibility  of  the 
skin.  Convulsions  may  occur,  but  are  usually  of  short  duration. 

1  Op.  oil.,  p.  127. 


DISEASES   DUE   TO   INHALATION    OF   DUST.  237 

The  chronic  form  of  aniline  poisoning  is  characterized  by 
three  sets  of  symptoms :  those  affecting  the  central  nervous 
system,  the  digestive  tract,  and  the  skin.  Among  the  first  are 
lassitude,  headache,  roaring  in  the  ears,  and  disturbances  of 
sensation  and  motion  of  greater  or  less  degree. 

The  digestive  derangements  consist  in  eructations,  nausea, 
and  vomiting. 

The  cutaneous  lesions  are  eczematous  or  pustular  eruptions, 
and  sometimes  round,  sharply-circumscribed  ulcers  with  callous 
borders. 

There  is  no  trustworthy  evidence  that  in  the  manufacture 
of  aniline  colors  poisonous  symptoms  are  produced  in  the 
workmen. 

II. — DISEASES    DUE    TO    THE    INHALATION    OF    IRRITATING    OR 
POISONOUS   DUST. 

The  inhalation  of  air  containing  particles  of  organic  or 
inorganic  matter  has  long  been  accepted  as  a  cause  of  certain 
special  diseases  of  artisans.  The  diseases  so  caused  are  usually 
limited  to  the  pulmonary  organs,  and  consist  of  acute  and 
chronic  catarrh,  emphysema  of  the  lungs,  pneumonia,  interstitial 
inflammation  of  the  lungs, — the  so-called  fibroid  phthisis  or  pul- 
monary cirrhosis. 

Coal-dust  is  inhaled  by  coal-miners,  charcoal-burners,  coal- 
handlers,  firemen,  chimney-sweeps,  foundry-men,  lead-pencil 
makers,  etc.  Chronic  bronchial  catarrhs  are  most  frequent, 
while  phthisis  and  emphysema  are  almost  absent  from  the  list 
of  diseases  affecting  these  workmen.  Dr.  W.  B.  Canfield  has 
reported  an  interesting  case  of  pneumonoconiosis  in  which  there 
was  coincident  bacillary  phthisis.1  The  table  on  page  208  shows 
that  the  expectation  of  life  of  foundry-men,  furnace-men,  fire- 
men, and  chimney-sweeps  is  much  below  the  average. 

Metallic  dust  is  inhaled  by  blacksmiths,  nailers,  cutlers,  lock- 
smiths, file-cutters,  cutlery-  and  needle-  polishers,  etc.  While 

1  Trans.  Med.  and  Chir.  Fac.,  Md.,  1889. 


238  TEXT-BOOK   OF   HYGIENE. 

in  this  class  of  workmen  cases  of  bronchitis  and  pneumonia 
are  relatively  frequent,  much  the  largest  proportion  suffer  from 
phthisis.  A  table  compiled  by  Hirt  shows  that  out  of  the  total 
number  of  sick  in  the  different  classes  of  workmen  the  cases  of 

phthisis  were : — 

62.2  per  cent,  for  file-cutters, 
69.6        "          "    needle-polishers, 
40.4        "  "    grinders, 

12.2        "  "    nailers. 

The  Massachusetts  table  gives  the  average  duration  of  life 
for  blacksmiths  at  53.26  years,  of  nail-makers  at  41.49  years, 
and  of  cutlers  at  39.21  years.  The  needle-polishers  at  Sheffield, 
as  already  stated  (page  210),  have  only  an  average  duration  of 
life  of  30.66  years.  In  this  work  and  that  of  grinding  knivesj 
scissors,  and  similar  articles,  the  metallic  dust  is  mixed  with 
mineral  dust  (particles  of  silica  from  the  grindstone).  This 
mixture  seems  to  be  much  more  deleterious  than  metallic  dust 
alone,  as  shown  by  the  shorter  average  duration  of  life  and  the 
enormous  percentage  of  cases  of  consumption. 

Mineral  dust  is  inhaled  by  the  workmen  in  a  large  number 
of  different  industries.  The  grinders  in  the  ground-glass  factories 
suffer  most  severely.  Hirt  found  the  average  duration  of  life  in 
grinders  who  began  this  occupation  after  their  25th  year  to  be 
42.50  years,  while  in  those  who  began  at  the  age  of  15  the 
average  duration  wras  30  years. 

Millstone  cutting  is  also  a  very  dangerous  occupation.  Pea- 
cock1 gives  the  average  age  of  these  workmen  at  24.1  years. 
Stone-cutters  generally  suffer  frequently  from  phthisis,  probably 
largely  in  consequence  of  the  constant  inhalation  of  the  mineral 
dust  produced  during  their  work.  The  Massachusetts  table  gives 
the  average  age  at  death  of  these  workmen  at  40.90  years, 
while  Hirt's  table  gives  a  much  lower  age,  namely  36.3  years. 
Potters  and  porcelain-makers  are  exposed  to  similar  dangers 
from  their  occupation,  but  to  a  much  less  degree.  The  table  on 

1  Quoted  by  Merkel,  in  von  Pettenkof  er  und  Ziemssen's  Handbuch  der  Hygiene,  II  Th., 
4  Abth.,  p.  197. 


DISEASES   DUE   TO   INHALATION    OF    DUST.  239 

page  208  gives  the  average  age  at  death  at  56.67  years, — rather 
a  high  average. 

Slaters  and  workmen  in  slate-quarries  suffer  in  a  large  pro- 
portion of  cases  from  chronic  pneumonia,  and  die  at  a  compara- 
tively early  age. 

Masons  and  carpenters  have  an  average  duration  of  life  of 
50.33  and  53.33  years,  respectively.  One-third  of  all  the  diseases 
from  which  they  suffer  affect  the  respiratory  organs. 

Gussenbauer  has  reported  a  very  interesting  series  of  cases 
of  a  peculiar  inflammatory  affection  of  the  diaphyses  of  the  long 
bones  in  the  artisans  who  are  engaged  in  the  manufacture  of 
pearl  buttons. 

Gem-finishers  are  exposed  not  .only  to  the  inhalation  of 
dust,  but  to  poisonous  gases  (carbon  monoxide)  and  vapors 
(lead).  The  proportion  of  sickness  among  them  is  very  high. 

Vegetable  Dust. — The  workmen  compelled  to  inhale  vege- 
table dust  are  those  who  work  in  tobacco,  cotton-operatives, 
flax-dressers,  paper-makers,  weavers,  wood-turners,  millers,  and 
laborers  in  grain-elevators. 

Workmen  in  tobacco  usually  suffer,  within  a  few  weeks 
after  beginning  work,  from  a  nasal,  conjunctival,  and  bronchial 
catarrh,  which  soon  passes  off,  as  the  mucous  membranes  seem 
to  become  accustomed  to  the  irritation.  Nausea  is  also  frequent 
at  first,  due  probably  to  the  absorption  of  small  quantities  of 
nicotine.  Females  exposed  to  tobacco-dust  usually  suffer  from 
digestive  and  nervous  troubles.  They  are  also  said  to  abort 
frequently. 

Dr.  R.  S.  Tracy,1  as  a  result  of  his  observations  among 
cigar-makers  in  New  York,  states  that  the  fecundity  of  these 
people  is  much  less  than  the  average.  Three  hundred  and 
twenty-five  families  visited  had  only  465  children,  an  average 
of  1.43  to  each  family.  Dr.  Tracy  is  inclined  to  attribute  this 
to  the  frequent  abortions  that  occur  among  the  females  exposed  to 
the  inhalation  of  tobacco-dust.  According  to  the  Massachusetts 

1  Buck's  Hygiene  and  Public  Health,  vol.  ii,  p.  62. 


240  TEXT-BOOK   OF    HYGIENE. 

table,  cigar-making  is  an  unfavorable  occupation,  the  average 
age  at  death  being  38.36  years. 

Cotton-operatives,  flax-dressers,  weavers,  and  workmen  in 
paper-mills  are  Subject  to  various  diseases  of  the  respiratory 
organs.  Coetsem,  as  long  ago  as  1836,  described  a  peculiar 
pulmonary  affection  among  cotton-operatives,  which  he  termed 
pneumonic  cotonneuse.  The  observation  does  not  seem  to  have 
been  verified  by  others ;  at  all  events,  the  author  is  unable  to 
find  any  other  record  of  a  similar  affection  in  the  literature  of 
the  subject.  Among  weavers  the  mortality  from  phthisis  is 
comparatively  high.  Among  paper-makers  Hirt  found  an 
average  duration  of  life  of  37.6  years.  The  people  who  sort 
rags  are  liable  to  a  fatal  infectious  disease,  "  rag-sorters'  disease" 
(Hademkrankheit1),  which  resembles  in  all  respects,  and  is  prob- 
ably nothing  less  than,  anthrax.  No  cases  have  been  reported 
in  this  country,  but,  as  the  importation  of  rags  from  abroad  is 
carried  on  to  a  considerable  extent,  no  apology  is  believed  to  be 
necessary  for  calling  attention  to  it.  The  "  wool-sorters'  disease," 
to  which  attention  has  recently  been  called  in  England,  is  doubt- 
less similar  in  its  nature. 

Millers  suffer  in  a  large  proportion  of  cases  from  pulmonary 
affections,  especially  bronchial  catarrh  and  pneumonia.  Accord- 
ing to  Hirt,  20.3  per  cent,  of  all  the  diseases  of  these  workmen 
are  pneumonias,  9.3  per  cent,  bronchial  catarrhs,  10.9  per  cent, 
phthisis,  and  1.9  per  cent,  emphysema.  The  average  duration 
of  life  is  45.1  years.  The  Massachusetts  table  gives  57.14  years, 
— a  very  much  more  favorable  exhibit. 

The  laborers  in  grain-elevators  are  compelled  to  inhale  a 
very  irritating  dust,  which  causes  acute  and  chronic  catarrhs  of 
the  respiratory  organs.  Dr.  T.  B.  Evans,  of  Baltimore,  has 
reported  a  series  of  cases  of  catarrhal  pneumonia  in  these  work- 
men, which  were  characterized  by  some  very  peculiar  features. 
Brush-making,  according  to  the  statistics  of  Hirt,  is  a  very  dan- 
gerous occupation.  Nearly  one-half  of  the  deaths  among  brush- 

f  1  See  article  by  Soyka,  Realencyclopaedie  d.  ges.  Heilk,  Bd.  VI,  p.  165. 


DISEASES   DUE   TO   POISONOUS    SUBSTANCES.  241 

makers  are  from  phthisis,  due,  in  great  measure,  to  the  inhalation 
of  the  sharp  fragments  of  bristles  produced  in  trimming  the 
brushes.  In  the  Massachusetts  table  the  average  duration  of 
life  is  given  at  43.11  years. 

III. DISEASES    DUE   TO    THE    ABSORPTION    OR    LOCAL   ACTION    OF 

.     IRRITATING   OR    POISONOUS    SUBSTANCES. 

Arsenic  is  used  in  the  manufacture  of  green  pigments  and 
for  various  other  purposes  in  the  arts.  In  the  preservation  of 
furs  and  in  taxidermy  it  finds  extensive  use.  In  the  prepara- 
tion of  the  pigment  known  as  Paris  green  the  workmen  are 
frequently  entirely  covered  by  a  layer  of  the  poisonous  salt.  The 
poisonous  symptoms  occur  in  consequence  of  the  absorption  of 
the  poison  through  the  skin  or  from  its  local  action,  and  but 
rarely  on  account  of  inhalation  of  vapors  or  dust  in  which  it  is 
contained.  The  most  marked  symptoms  are  chronic  gastric 
catarrh,  superficial  erosions  in  the  mouth,  dry  tongue,  thirst,  and 
a  burning  sensation  in  the  throat.  Tljese  symptoms  may  con- 
tinue for  months,  or  even  years,  and  gradually  produce  a  com- 
plete breaking  down  of  nutrition  and  the  vital  powers.  Violent 
itching  skin  eruptions  of  an  eczematous  character  are  not  infre- 
quent complications  of  the  internal  symptoms. 

Lewin  has  described  a  localized  pigmentation  of  the  skin 
in  workmen  (engravers)  in  silver.  The  left  hand  is  especially 
affected.  The  occurrence  of  the  affection  is  explained  by  the 
numerous  slight  injuries  of  the  hands  by  the  graver's  tools  and 
the  local  absorption  and  decomposition  of  the  silver. 

Phosphorus  produces  two  classes  of  effects  in  persons  sub- 
jected to  its  influence.  The  milder  effects  are  produced  by  the 
inhalation  of  the  fumes  of  the  substance,  and  are  limited  to 
digestive  disturbances  and  diseases  of  the  pulmonary  organs. 
The  severer  symptoms  are  only  observed  among  the  employes 
in  match-factories,  and  are  due  to  the  local  action  of  the  phos- 
phorus upon  the  tissues  affected. 

The  characteristic  disease  produced  by  phosphorus  is  a 


10 


242  TEXT-BOOK   OF   HYGIENE. 

painful  periostitis  of  the  lower  or  upper  jaw.  The  limitation 
of  the  affection  to  this  locality  is  believed  to  be  due  to  the  action 
of  the  phosphorus  dissolved  in  the  saliva.  The  fact  that  the 
lower  jaw,  with  which  the  saliva  comes  more  thoroughly  in 
contact,  is  most  frequently  affected  seems  to  indicate  that  this 
view  is  the  correct  one.  The  disease  begins,  on  an  average,  five 
years  after  the  beginning  of  the  employment.  Hirt  estimates 
the  proportion  of  employes  in  match-factories  attacked  at  11  to 
12  per  cent.  The  first  symptom  of  the  disease  is  toothache, 
soon  extending  to  the  jaw.  The  cervical  glands  swell  up ;  the 
gums  become  reddened  and  spongy ;  abscesses  form  about  the 
diseased  teeth,  from  which  large  quantities  of  thin,  offensive  pus 
are  discharged.  Examination  with  a  sound  reveals  carious, 
nodulated  bone.  The  cheeks  become  swollen,  erysipelatous, 
and  may  suppurate  and  discharge  pus  externally. 

Hutchinson  has  reported  a  case  in  which  the  long-continued 
internal  administration  of  phosphorus  as  a  medicine  produced 
maxillary  necrosis. 

The  destruction  of  the  soft  tissues  continues  until  resection 
of  the  jaw. is  finally  undertaken  and  the  disease  checked  by 
surgical  interference,  and  removal  of  the  patient  from  the  influ- 
ence of  the  pernicious  substance. 

Dr.  J.  Ewing  Mears  reports1  16  cases  of  phosphorus  ne- 
crosis. He  concludes  "  that  the  antidotal  powers  of  turpentine 
have  been  established,  both  in  neutralizing  the  effects  of  the 
poison  upon  operatives  during  their  work  and  also  in  the  treat- 
ment of  the  early  stage  of  the  disease.  The  disease  is  to  be 
prevented  by  the  adoption  of  thorough  methods  of  ventilation, 
stringent  rules  with  regard  to  cleanliness,  and  the  free  disen- 
gagement of  the  vapors  of  turpentine  in  all  the  apartments  of 
factories  in  which  the  fumes  of  phosphorus  escape." 

In  the  manufacture  of  quinine  a  troublesome  eczema  is 
caused  in  about  90  per  cent,  of  the  employes.  It  seems  to  be 
due  to  emanations  given  off  from  the  boiling  solutions.  It 

1  Trans.  Am.  Surg.  Association,  1887. 


DISEASES   DUE   TO   ELEVATED   OR   VARIABLE   TEMPERATURE.       243 

begins  with  intense  itching,  followed  by  swelling  and  the  forma- 
tion of  vesicles,  which  soon  burst  and  form  crusts.  There  is 
considerable  fever  when  the  swelling  is  great.  It  is  said  that 
blondes  are  more  frequently  affected  than  those  of  dark  com- 
plexion. The  disease  soon  disappears  if  the  work  is  given  up. 

The  workmen  engaged  in  the  manufacture  of  bichromate 
of  potassium  are  said  to  suffer  from  an  ulceration  of  the  nasal 
mucous  membrane  very  similar  to  that  already  described  as  due 
to  the  vapors  of  hydrochloric  acid  (p.  212).  Rapidly  spreading, 
deep  ulcers  are  also  said  to  form  if  the  bichromate  comes  in 
contact  with  abraded  surfaces  of  the.  skin. 

The  strong  alkali  handled  by  tanners  frequently  produces 
fissured  eczemas  of  the  hands,  which  are  painful  and  often  diffi- 
cult to  cure. 

The  workmen  in  petroleum  refineries  frequently  suffer  from 
acneiform  or  furuncular  eruptions. 

Among  glass-blowers,  syphilis  is  frequently  communicated 

by  an  infected  mouth-piece  which  is  used  by  the  men  in  turn. 

• 

IV. DISEASES   DUE   TO   EXPOSURE   TO   ELEVATED   OR  VARIABLE 

TEMPERATURE    OR   ATMOSPHERIC   PRESSURE. 

Cooks  and  bakers  are  exposed  almost  constantly  to  a  high 
temperature,  which  produces  an  unfavorable  influence  upon 
health  and  predisposes  them  to  diseases  of  various  kinds.  The 
Massachusetts  table  shows  that  cooks  have  a  much  shorter 
duration  of  life  than  bakers,  although  the  statistics  of  both 
trades  are  unfavorable. 

The  prevailing  diseases  among  cooks  and  bakers  are  rheu- 
matism and  eczematous  eruptions,  generally  confined  to  the 
hands,  forearms,  and  face. 

Blacksmiths,  founders,  and  firemen  suffer  from  the  intense 
heat  to  which  they  are  exposed,  in  addition  to  the  inhalation  of 
coal-dust,  as  has  already  been  pointed  out.  The  stokers  in  the 
engine-rooms  of  steam-ships  suffer  especially  from  the  excessively 
high  temperature  to  which  they  are  subjected  by  their  occupation. 


244  TEXT-BOOK   OF   HYGIENE. 

A  form  of  heart-weakness,  described  by  Levick  as  "  fireman's 
heart,"  is  prevalent  among  them. 

Sailors,  farmers,  coachmen,  car-drivers,  and  teamsters  are 
subjected  to  stress  of  weather,  changes  of  temperature,  and 
storms.  They  surfer  frequently  from  rheumatism,  acute  bron- 
chitis, pneumonia,  and  Bright's  disease.  Car-drivers  are  said 
also  to  surfer  from  painful  swelling  of  the  feet,  varicose  veins 
and  ulcers,  and  mild  spinal  troubles.1 

Sun-stroke  is  not  confined  to  any  class  of  artisans,  but 
persons  who  perform  very  hard  labor,  especially  in  a  confined 
atmosphere,  suffer  most  frequently. 

The  effects  of  compressed  air  on  workmen  in  tunnels  and 
deep  mines  has  already  been  referred  to.2  The  most  serious 
symptoms  occur  not  when  the  individual  is  subjected  to  the 
increased  pressure,  but  when  the  pressure  is  too  rapidly  dimin- 
ished. 

V. DISEASES   DUE   TO   THE   EXCESSIVE   USE   OF    CERTAIN    ORGANS. 

The  prevalent  belief  that  the  overuse  of  the  intellectual 
faculties  is  a  frequent  cause  of  mental  disease  is  not  borne  out 
by  facts.  Men  and  women  who  perform  an  amount  of  mental 
work  regarded  by  most  persons  as  excessive  have,  in  spite  of 
this,  a  long  duration  of  life.  There  are  no  exact  statistics  upon 
this  subject,  but  Caspar,  half  a  century  ago,  made  the  following 
estimate  of  the  average  duration  of  life  among  professional  men  : 
Clergymen  live  65;  merchants,  62.4;  officials,  61.7  ;  lawyers, 
58.9 ;  teachers,  56.9,  and  physicians,  56.8  years.  In  the  table 
on  page  209  the  figures  are  somewhat  less  favorable,  although 
corresponding  in  general  with  those  of  Caspar.  Hence,  it  is 
seen  that,  of  professional  men,  those  whose  occupation  compels 
the  exercise  of  high  mental  powers  have  a  higher  duration  of 
life  than  any  other  class,  except  farmers  and  mechanics  engaged 
actively  out  of  doors.  '  Those  professional  occupations  only 
which  necessitate  a  more  or  less  irregular  mode  of  life  and 

1  A.  McL.  Hamilton  in  Report  New  York  Board  of  Health,  p.  444, 1873. 
*  Chapter  I,  p.  12. 


DISEASES   DUE   TO   A   SEDENTARY   LIFE.  245 

frequent  subjection  to  physical  exhaustion  and  dangers-  from 
contagious  disease,  such  as  the  work  of  physicians  and  journal- 
ists, make  an  unfavorable  showing  in  the  statistics.  The  prop- 
osition may  be  laid  down  that  it  is  not  mental  activity,  however 
great,  but  mental  worry  that  tends  to  the  abbreviation  of  life. 

The  occupation  of  a  tea-taster  is  said  to  produce  a  peculiar 
nervous  condition,  manifested  in  muscular  tremblings,  etc., 
which  compels  the  individual  to  give  up  the  work  in  a  few  years. 

Persons  who  test  the  quality  of  tobacco,  an  occupation  corre- 
sponding to  that  of  tea- taster,  are  said  to  suffer  from  nervous  symp- 
toms, which  may  include  amaurosis  and  other  grave  affections. 

Those  persons  who  are  compelled  to  use  their  eyes  con- 
stantly upon  minute  objects  frequently  suffer  from  defective 
vision.  So  engravers,  watch-makers,  and  seamstresses  are  liable 
to  near-sightedness,  amaurosis,  and  irritation  of  the  conjunctiva. 
Public  speakers  and  singers  frequently  suffer  from  catarrhal  or 
even  paretic  conditions  of  the  throat,  which  usually  disappear 
on  relinquishing  the  occupation  for  a  time. 

Telegraph  operators  and  copyists  suffer  from  a  peculiar 
convulsive  affection  of  the  fingers,  called  "  writers'  cramp." 
Cigar-makers  are  also  said  to  suffer  from  a  similar  cramp  of 
the  fingers  used  in  rolling  cigars.  Performers  on  wind  instru- 
ments are  liable  to  pulmonary  emphysema,  on  account  of  the 
pressure  to  which  the  lungs  are  frequently  subjected.  Boiler- 
makers often  suffer  from  deafness,  .in  consequence  of  their 
constant  existence  in  an  atmosphere  in  a  state  of  continual  violent 
vibration.  The  affection  is  generally  recognized  as  "  boiler- 
makers'  deafness."  Dr.  C.  S.  Turnbull  has  reported  several 
cases  of  "  mill-operatives'  deafness."  Its  characteristic  is  an 
inability  to  hear  distinctly  except  during  a  noise. 

VI. DISEASES   DUE   TO   A   CONSTRAINED    ATTITUDE   AND 

SEDENTARY    LIFE. 

It* is  probable  that  the  large  mortality  and  morbility  rate 
of  persons  whose  occupations  keep  them  confined  within  doors 


246  TEXT-BOOK   OF   HYGIENE. 

are  due,  next  to  the  defective  ventilation,  to  the  constrained 
attitude  which  most  of  them  necessarily  assume.  Thus,  carvers, 
book-binders,  engravers,  jewelers,  printers,  shoe-makers,  book- 
keepers, and  cigar-makers  all  have  a  low  average  duration  of 
life.'  It  is  found,  likewise,  that  many  of  these  artisans  suffer 
most  from  pulmonary  and  digestive  troubles,  among  the  former 
being  phthisis,  and  among  the  latter  constipation,  dyspepsia,  and 
haemorrhoids. 

VII. — DISEASES    FROM   EXPOSURE   TO   MECHANICAL   VIOLENCE. 

It  will  be  seen,  by  reference  to  the  table  on  page  209,  that 
all  persons  whose  occupations  involve  an  intimate  contact  with 
machinery,  and  in  the  pursuit  of  which  accidents  frequently 
happen,  have  a  short  duration  of  life.  Persons  liable  to  these 
dangers  are  machinists,  operatives  in  factories,  workmen  in 
powder-mills,  baggage-masters,  brakemen,  drivers,  engineers, 
firemen,  and  other  workmen  on  railroads.  Aside  from  the 
diseases  to  which  some  of  these  classes  are  liable  in  consequence 
of  exposure  to  variable  atmospheric  conditions,  the  grave  acci- 
dents to  which  they  are  so  frequently  exposed  render  their 
occupations  extremely  dangerous.  Brakemen  on  freight  rail- 
roads, for  example,  are  classed  by  insurance  companies  as  the 
most  hazardous  "  risks,"  and  some  companies  refuse  to  take  them 
at  all.  The  table  on  page  209  tends  to  confirm  the  conclusion  of 
the  insurance  companies,  for,  excluding  the  class  of  "  students," 
which,  for  manifest  reasons,  cannot  be  used  as  a  comparison, 
brakemen  have  the  shortest  average  duration  of  life  of  all  the 
occupations  noted  in  the  table. 

[The  student  is  referred,  for  more  complete  information  on 
the  subjects  considered  in  the  foregoing  chapter,  to  the  following 
works : — 

L.  Hirt,  Die  Krankheiten  der  Avbeiter. — Eulenburg,  Handbuch  der 
Gewerbehygiene. — Layet,  Hj'giene  des  Professions  et  des  Industries. — 
Arlidge,  The  Diseases  of  Occupations.] 


QUESTIONS   TO    CHAPTER   IX. 

INDUSTRIAL  HYGIENE. 

How  may  various  occupations  induce  disease?  Are  such  diseases 
always  necessarily  due  to  the  occupations,  or  are  there  incidental  factors 
that  might  be  avoided?  What  classes  of  men  have  the  greatest  expecta- 
tion of  life?  What  occupations  are  especially  unfavorable  to  health? 
What  diseases  do  they  usually  produce?  How  may  diseases  of  occupa- 
tions be  conveniently  classified? 

What  disorders  are  liable  to  be  produced  by  the  inhalation  of  the 
gases  of  the  mineral  acids?  What  peculiar  symptoms  may  be  due  to 
the  constant  inhalation  of  the  fumes  of  hydrochloric  acid?  What  effect 
has  ammonia  gas?  What  disease  is  frequently  due  to  the  constant 
inhalation  of  chlorine  gas?  What  other  disease  is  also  especially 
favored  by  it?  What  are  some  of  the  symptoms  produced  by  the  gas 
in  a  concentrated  state  ?  By  the  constant  inhalation  of  the  gas  ? 

In  what  occupations  is  carbon  monoxide  often  given  off  to  the  air? 
What  are  some  of  the  acute  symptoms  produced  by  it  ?  What  of  the 
chronic  poisoning  by  the  gas  ?  Is  there  any  evidence  that  carbon  diox- 
ide in  small  amounts  may  cause  symptoms  of  chronic  poisoning?  What 
are  some  of  the  manifestations  in  cases  of  acute  poisoning  by  this  gas  ? 
What  other  gas  is  often  found  in  mines,  and  how  may  it  be  dangerous  to 
life  ?  How  may  its  dangers  be  avoided  ? 

Where  may  sulphuretted  hydrogen  be  found  in  quantities  sufficient 
to  produce  serious  results?  What  are  some  of  the  evil  effects  due  to  the 
inhalation  of  the  vapor  of  bisulphide  of  carbon?  Of  iodine  and  bro- 
mine? Of  turpentine?  Of  petroleum? 

In  what  occupations  are  the  laborers  subject  to  lead  poisoning? 
What  effect  has  it  on  the  duration  of  life?  In  what  forms  may  lead 
poisoning  manifest  itself?  What  proportion  of  workers  in  lead  are 
affected  by  it? 

What  proportion  of  workers  in  mercury  are  affected  by  that  metal  ? 
To  what  disease  -are  mirror-makers  especially  prone  ?  What  are  some 
of  the  symptoms  of  mercurial  intoxication?  What  peculiar  effect  has 
the  metal  upon  female  laborers  and  their  children  ?  How  may  the  bad 
effects  of  mercury  be  diminished  ? 

What  are  the  symptoms  of"  brass-founders'  ague"?  Is  it  common 
among  the  class  indicated  ?  What  S3'mptoms  may  indicate  chronic  zinc 
poisoning  ? 

What  are  the  symptoms  of  acute  poisoning  by  aniline  vapor  ?  What 
peculiarities  characterize  chronic  aniline  poisoning?  Are  these  or  others 
liable  to  be  produced  in  those  employed  in  the  manufacture  of  aniline 
colors  ? 

(247) 


248  QUESTIONS   TO   CHAPTER   IX. 

What  class  of  diseases  is  especially  apt  to  be  caused  by  the  con- 
tinued inhalation  of  dust?  What  is  the  most  common  affection  among 
those  who  inhale  coal-dust  in  large  quantities?  From  what  pulmonary 
disease  are  they  exceptionally  free?  Is  the  expectation  of  life  among 
this  class  of  workmen  high?  What  diseases  seem  to  be  especially 
favored  by  the  inhalation  of  metallic  dust?  Which  of  these  is  the  most 
frequent  ?  What  is  the  effect  of  a  mixture  of  metallic  and  mineral 
dust?  What  occupations  have  a  high  morbidity  and  mortality  from 
phthisis?  What  from  chronic  pneumonia  or  other  pulmonary  affections  ? 
To  what  peculiar  affection  are  pearl-button-makers  subject  ? 

What  workmen  habitually  inhale  vegetable  dust?  What  disturb- 
ances are  due  to  the  inhalation  of  tobucco-dust?  What  effect  has  it  on 
fecundity,  and  why  ? 

To  what  diseases  are  workers  in  cotton  and  flax  subject,  and  from 
which  one  especially  is  the  moi'tality  high?  What  is  the  average  dura- 
tion of  life  among  paper-makers  ?  To  what  disease  are  rag-  and  wool- 
sorters  liable  ?  From  what  affections  do  millers  and  workers  in  grain- 
elevators  suffer?  Why  is  the  mortality  from  phthisis  so  high  among 
brush-makers  ? 

What  substances  are  liable  to  cause  disease  b}T  absorption  or  local 
action?  What  are  some  of  the  symptoms  common  to  those  working 
with  arsenic  ?  What  two  classes  of  effects  are  observed  among  those 
exposed  to  phosphorus  vapors?  To  what  is  each  class  due?  What 
may  be  used  as  a  preventive  and  antidote  to  such  cases  of  phosphorus 
poisoning?  AVhat  malady  is  associated  with  the  manufacture  of  qui- 
nine ?  What  other  substances  ma}'  produce  eczema  or  ulceration  in  their 
preparation  or  manufacture? 

What  diseases  are  favored  by  continued  exposure  to  high  tempera- 
tures ?  In  what  occupations  are  such  disturbances  accordingly  prevalent  ? 
What  class  of  laborers  are  subject  to  sudden  changes  or  to  extremes  of 
temperature?  What  are  some  of  the  maladies  that  may  be,  in  part, 
traced  to  such  causes?  What  are  the  effects  of  compressed  air  upon 
laborers  in  it,  and  when  are  they  manifested  ? 

What  diseases  or  disturbances  may  be  due  to  the  excessive  use  of 
certain  organs  ?  Is  there  any  evidence  that  excessive  mental  activit}- 
leads  to  mental  disease?  What  is  a  factor  in  the  production  of  the 
latter?  Why  is  the  mortality-rate  so  high  among  those  who  follow 
sedentary  or  in-door  occupations  ?  What  disturbances  are  most  common 
to  these  pursuits  ?  In  what  occupations  are  the  laborers  especially  liable 
to  mechanical  violence  ?  Is  the  average  duration  of  life  of  such  work- 
men low  or  high  ? 


CHAPTER  X. 

MILITARY  AND  CAMP  HYGIENE. 

•'     i* 

THE  subjects  embraced  in  this  chapter  can  be  most  con- 
veniently arranged  under  the  following  heads : — 

I.  The  Soldier  and  his  Training.          IV.  The  Dwelling  of  the  Soldier. 
II.  The  Food  of  the  Soldier.  V.  Camp  Diseases. 

III.  The  Clothing  of  the  Soldier.  VI.  Civilian  Carnps. 

I. THE    SOLDIER    AND    HIS   TRAINING. 

The  relations  existing  among  different  nations  at  the  present 
time  require  that  a  standing  army  of  greater  or  less  number  be 
maintained  by  each  for  the  common  safety.  This  being  the 
case,  it  needs  no  argument  to  prove  that  such  an  army  should 
be  composed  of  the  best  material  available  in  order  that  it  may 
be  depended  upon  for  defense  or  offense  when  necessity  demands 
that  it  should  be  called  into  active  service. 

Hammond  says  with  truth1  that  "  a  weak,  malformed,  or 
sickly  soldier  is  not  only  useless  but  a  positive  incumbrance  "  to 
an  army.  It  is  of  the  first  importance,  therefore,  to  exclude 
from  the  military  service,  by  a  rigorous  physical  examination,  all 
individuals  whose  physical  condition  is  defective,  who  are  either 
suffering  from  or  predisposed  to  disease. 

The  foremost  authorities  on  military  hygiene  are  agreed 
that  no  recruit  should  be  enlisted  for  actual  service  before  the 
20th  year.  In  the  English  army  the  lowest  age  at  present  is 
19  years ;  in  Germany,  20  years ;  in  France,  20  years  for  actual 
service  (recrues),  18  years  for  enlistment  (engages);  and  in  the 
United  States,  21  years.  The  limit  of  age  upward  in  the  latter 
army  is  45  years,  except  in  cases  of  re-enlistments.  The  height 
of  recruits  must  be  at  least  165  centimetres;  minimum  chest 

1  Hygiene,  p.  19.    Philadelphia,  1863. 

(249) 


250  TEXT-BOOK   OF   HYGIENE. 

measurement  75  centimetres,  with  at  least  5  centimetres'  expan- 
sion ;  and  weight  from  54  to  81  kilogrammes.  In  the  cavalry 
service  the  maximum  weight  is  75  kilogrammes.  Every  recruit 
must  be  vaccinated  before  enlistment. 

The  physical  examination  of  recruits  before  enlistment 
must  be  made  by  a  medical  officer,  whose  decision,  in  the  United 
States  army,  is  definitive.  In  the  German  army  the  decision  of 
the  medical  officer  is  not  final,  but  subject  to  revision  by  the 
recruiting  officer,  who  may,  if  he  sees  fit,  overrule  the  medical 
officer's  opinion  and  enlist  a  man  who  has  been  decided  to  be 
unqualified  for  the  military  service.  In  this  and  various  other 
respects,  such  as  pay,  rank,  and  effective  power,  the  Medical 
Staff  of  the  United  States  Army  has  many  advantages  over  that 
of  most  foreign  armies. 

II. THE   FOOD   OF   THE   SOLDIER. 

The  army  ration  of  the  United  States,  which  is  given  below, 
was  fixed  by  regulations  before  the  more-recent  researches  of 
Professor  Voit  on  nutrition  were  completed.  The  ultimate  com- 
position, which  yields  142  grammes  proteids,  116  grammes  fats, 
and  435  grammes  carbohydrates,  shows  an  excess  of  fats  and 
deficiency  of  carbohydrates.  Table  XXI  shows  the  daily  allow- 
ance for  each  soldier : — 

TABLE  XXI. 

342  grammes  pork  or  bacon,  or 
567         "         fresh  beef. 
454         "         hard  bread,  or 
566        "         flour. 
68  beans  or  peas,  or 

45  rice  or  hominy. 

45        "         green  coffee. 
17         "         salt. 
68         "         sugar. 

To  this  is  also  added  vinegar,  pepper,  and  tea  in  place  of 
coffee.  Although  the  regular  food-allowance  in  the  United  States 
army  is  liberal,  and  is  largely  in  excess  of  the  needs  of  the  soldier 


THE   CLOTHING    OF   THE    SOLDIER.  251 

• 

in  garrison,  medical  officers  generally  agree  that  in  active  service 
it  is  insufficient  in  quantity  and  not  sufficiently  varied. 

The  money  value  of  each  of  the  above  articles  in  the  ration 
is  fixed  by  the  government,  and  may  be  drawn  instead  of  certain 
of  the  articles,  and  other  articles  of  food  purchased  and  thus 
the  dietary  varied.  The  money  so  drawn  constitutes  what  is 
known  as  the  "  company  fund."  In  the  hands  of  a  judicious 
commanding  officer,  the  company  fund  can  be  made  a  source 
of  great  benefit  and  comfort  to  the  men,  but  that  it  is  at 
times  mismanaged  or  misapplied  is  well  known  to  army  sur- 
geons. 

Aside  from  the  insufficient  quantity  and  variety  of  food 
furnished  to  soldiers,  the  cooking,  especially  in  temporary  camps, 
is  often  defective  and  causes  digestive  derangements  and  con- 
sequent innutrition.  A  good  cook  should  be  attached  to  every 
company. 

in. THE   CLOTHING   OF   THE    SOLDIER. 

The  clothing  of  the  United  States  soldier  is  tolerably  well 
adapted  to  its  uses.  It  is  generally  well  made,  and  of  good, 
serviceable  material.  The  only  exception  that  can  be  made  with 
reason  is  that  the  foot-gear  is  not  made  to  individual  measure, 
and  hence  peculiarities  of  shape  of  the  feet  cannot  be  taken 
account  of.  For  this  reason  painful  affections  of  the  feet,  due  to 
ill-fitting  boots  or  shoes,  are  of  frequent  occurrence. 

When  on  a  march,  the  soldier  carries  his  extra  clothing 
packed  in  a  knapsack  and  strapped  upon  the  back.  His 
blankets  and '  great-coat  are  rolled  into  a  cylinder  and  strapped 
upon  the  knapsack.  The  weight  each  soldier  has  thus  to  carry, 
in  addition  to  his  arms  and  ammunition,  amounts  to  considerable. 
There  is  reason  to  believe  that  the  pressure  produced  by  the 
straps  of  a  heavy  knapsack  may  cause  not  only  discomfort  but 
actual  disease.  It  is  believed  by  many  officers  that  the  knapsack 
could  be  abolished  with  advantage,  and  the  extra  clothing  rolled 
up  in  the  blanket,  or  a  water-proof  sheet,  and  slung  over  the 
left  shoulder. 


252  TEXT-BOOK   OF   HYGIENE. 

IV. THE   DWELLING   OF   THE    SOLDIER. 

Soldiers  are  generally  housed  either  in  barracks,  huts,  or 
tents.  The  former  are  usually  the  habitation  of  the  soldiers 
in  garrisons  or  permanent  camps,  while  huts  or  tents  are 
used  for  the  purpose  of  sheltering  the  occupants  of  temporary 
camps. 

Barracks. — A  military  barrack  is  a  one-storied  building 
constructed  of  stone,  wood,  or  iron,  or  a  combination  of  these 
materials.  The  general  plan  of  the  barrack  comprises  a  large 
room  for  the  beds  of  the  soldiers,  one  or  more  smaller  rooms 
for  the  non-commissioned  officers  of  the  company  or  squad,  and 
a  wash-room.  The  sleeping-room  of  the  soldier  is  also  his  living- 
or  day-  room.  It  is  evident,  therefore,  that  sufficient  air-space 
and  good  ventilation  must  be  provided  if  the  soldier's  health  is  to 
be  maintained.  In  England,  17  cubic  metres  are  recommended 
for  the  initial  air-space.  In  the  new  barracks  constructed  in 
France  according  to  the  plans  of  M.  Toilet,  22  cubic  metres  are 
allowed  to  each  occupant. 

The  special  points  of  distinction  of  the  system  of  Toilet,  of 
which  Schuster  says  that  "to  it  belongs  the  future  of  barrack 
construction,"  are  :  The  frame  of  the  building  is  of  light-iron 
ribs ;  the  interspaces  are  walled  up  with  bricks  or  stone ;  the 
roof  is  slate ;  the  ceiling  is  arched,  and  all  corners  are  rounded  to 
prevent  lodgment  of  dust.  Ventilation  is  provided  by  openings 
in  the  walls  at  the  edge  of  the  roof  for  the  entrance  of  fresh  air, 
and  by  ridge  ventilators. 

In  France,  barracks  have  been  built  according  to  Toilet's 
system  at  Bourges,  Cosne,  Macon,  and  Autun.  Although  occu- 
pied but  a  short  time,  it  appears  that  the  health  of  the  soldiers 
remains  better  in  them  than  in  the  barracks  constructed  on  the 
old  style.  The  system  would  seem  also  especially  to  lend  itself 
to  the  construction  of  hospitals.  The  wash-  and  bath-  rooms  of 
the  barracks  should  be  so  arranged  as  to  encourage  the  soldier 
to  cleanliness.  Where  the  only  lavatory  in  a  barrack  is,  as 
the  author  has  seen  it,  an  open  porch,  men  are  not  likely  to 


THE   DWELLING   OF  THE   SOLDIER.  253 

spend  much  time  in  cold  weather  in  washing  their  faces  and 
hands,  to  say  nothing  of  the  rest  of  their  bodies. 

The  kitchen  and  dining-room  should  be  detached  from  the 
building  serving  as  quarters ;  otherwise  the  odors  of  the  cooking 
will  pervade  the  building. 

The  sinks  or  latrines  should  be  placed  at  some  distance  from 
the  quarters  and  kitchen,  and  out  of  the  line  of  prevailing  winds. 
The  writer  has  personal  knowledge  of  a  permanent  military  post 
within  a  few  miles  of  the  city  of  Washington,  where,  only  a  few 
years  ago  (and,  for  aught  known  to  the  contrary,  at  the  present 
day),  "  the  rear,"  or  place  of  depositing  excrement,  was  about 
70  metres  distant  from  the  kitchen  and  men's  quarters,  and 
directly  in  line  with  the  prevailing  winds ! 

Before  erecting  any  buildings  it  is,  of  course,  necessary  to 
endeavor  to  secure  a  clean  and  dry  subsoil.  Attention  is  called  to 
the  principles  underlying  the  construction  of  dwellings,  Chap.  VI. 

Tents  and  Huts. — The  tents  used  in  the  army  are  the  hos- 
pital-tent, the  officers'  wall- tent,  the  A -tent,  and  the  shelter- 
tent,  which  is  a  modification  of  the  last.  The  conical,  or  Sibley 
tent,  which  was  frequently  seen  in  camps  in  the  early  part  of 
the  war  between  the  States,  has  gone  out  of  use.  Soldiers  give 
the  preference  to  the  shelter  tent,  which  is  light,  each  man's 
piece  weighing  only  1.18  kilogrammes.  Two  pieces  being 
joined  together  by  buttons  and  button-holes,  and  thrown  over  a 
ridge-pole  supported  upon  uprights,  and  the  four  corners  fast- 
ened to  pegs  driven  into  the  ground,  form  a  tent  1.20  metres 
high,  1.65  metres  long,  and  having  a  spread  at  the  base  of 
between  1.8  and  2.1  metres.  Such  a  tent  will  form  a  comfort- 
able shelter  for  two  men,  unless  there  should  be  strong  winds  or 
driving  rains,  when  the  ends  could  be  closed  by  blankets,  brush, 
or  an  extra  piece  of  shelter-tent.  The  uprights  and  ridge  are 
steadied  by  short  guy-ropes,  one  of  which  is  furnished  with 
each  piece  of  the  tent. 

In  winter,  especially  when  camps  of  more  or  less  perma- 
nence are  formed,  the  soldiers  usually  build  log  huts.  The 


254 


TEXT-BOOK   OF   HYGIENE. 


interstices  between  the  logs  are  plastered  up  with  mud  or  clay, 
and  the  roof  is  formed  of  canvas,  generally  several  pieces  of 
shelter  tent  joined  together. 

The  ground  around  the  tent  or  hut  should  be  trenched  in 
order  to  carry  off  the  rain-fall. 

Cleanliness  within  and  around  tents  or  huts  is  of  the  first 
importance,  and  should  be  enforced  in  all  camps  by  the  proper  au- 
thority. Military  authorities  have  long  since  learned  that  in  the 
matter  of  cleanliness  of  body,  clothing,  or  surroundings  voluntary 
action  on  the  part  of  the  soldier  cannot  be  relied  upon.  Frequent 
and  thorough  inspections  will  alone  secure  proper  cleanliness. 

V. CAMP  DISEASES. 

The  soldier's  profession  has  been  aptly  characterized  by 
Ruskin  as  "  the  trade  of  being  slain."  In  the  late  war  between 
the  States,  the  total  deaths  of  the  Federal  army  numbered  359,496, 
— over  15  per  cent,  of  the  entire  number  of  enlistments.  Of  this 
number,  however,  224,586  (nearly  two-thirds)  died  from  disease, 
while  the  remaining  134,910  (a  small  fraction  over  one-third)  were 
killed  in  battle  or  died  from  the  effects  of  wounds.  The  colored 
troops  especially  suffered  greatly  from  the  effects  of  disease. 

Diarrhcea  and  Dysentery. — The  most  fatal  diseases  of  camp 
life,  especially  in  time  of  war,  are  diarrhoea  and  dysentery.  The 
statistics  of  the  Federal  army  during  the  late  war  are  given  in 

the  following  table1:  — 

TABLE  XXII. 

Total  Deaths  from  Diarrhoea  and  Dysentery  in  the  U.  8.  Army,  from  May  1,  1861, 

to  June  30,  1866. 


White  Troops,  from 
May  1,  1861.  to  June 
30,1866. 

Colored  Troops, 
from  July  1,  1863, 
to  June  30,  1866. 

Total 

Acute  Diarrhoea   .... 
Chronic  Diarrhoea    .    .    . 
Acute  Dysentery  .... 
Chronic  Dysentery  .    .    . 

Cases. 
1,155,226 
170,488 
233.812 
25,670 

Deaths. 
2,923 

27,558 
4,084 
3,229 

Cases. 
113,801 
12.098 
35,259 

2,781 

Deaths 
1,368 
3.278 
1,492 
626 

Cases. 

1,269,027 
182.586 
259,071 
28,451 

Deaths 
4.291 
30,836 
5.576 
3,855 

Total           

1,585,196 

37,794 

153,939 

6,764 

1,739,135 

44,558 

1  Medical  and  Surgical  History  of  the  War,  second  medical  volume,  p.  2. 


CAMP   DISEASES.  255 

Owing  to  the  fact  that  a  considerable  number  of  deaths 
were  reported  without  assigning  any  cause,  Dr.  Woodward  esti- 
mates the  total  number  of  deaths  from-  the  above  diseases  at 
57,265,  or,  in  the  proportion  of  one  death  from  diarrhoea  and 
dysentery  to  three  and  one-half  deaths  from  all  diseases.  Among 
the  prisoners  of  war  held  by  the  Confederate  States  in  Anderson- 
ville  prison,  where  tolerably  complete  records  were  kept,  more 
than  half  the  total  deaths  were  from  diarrhoea  and  dysentery, 
while  the  ratio  of  deaths  to  cases  of  the  above  two  diseases  was  a 
fraction  over  76  per  cent.  This  frightful  mortality  from  these 
two  diseases,  both  in  the  prisons  and  among  the  armies  in  the 
field,  is  principally  due  to  the  insanitary  conditions  surrounding 
the  soldiers.  Where  the  demands  of  hygiene  were  especially 
ignored ;  where  the  food  was  bad  in  quality,  or  badly  cooked ; 
the  water  impure ;  the  soil  polluted  by  excreta  and  other  filth ; 
where  the  men  were  exposed  to  stress  of  weather  or  to  a  paludal 
atmosphere; — under  these  conditions,  the  above  diseases  of  the 
intestines  prevailed  in  their  greatest  extent  and  most  fatal 
degree. 

Malarial  Fevers. — The  diseases  due  to  the  paludal  poison 
are  exceedingly  frequent  among  soldiers  encamped  in  malarial 
sections.  During  the  Civil  War  a  very  pernicious  form  of  malarial 
fever  received  the  designation  of  the  locality  in  which  it  prevailed, 
and  passed  into  the  literature  under  the  name  of  "  Chickahominy 
fever."  While  malarial  diseases  were  largely  represented  in  the 
morbility  reports  during  the  war,  the  most  serious  results  of  the 
influence  of  the  malarial  poison  were  manifested  in  its  effects 
upon  patients  sick  with  other  diseases.  Thus,  typhoid  fever, 
dysentery,  or  pneumonia,  in  a  patient  saturated  with  malaria, 
was  very  much  more  serious  than  where  this  complication  was 
absent.  In  the  malarial  regions  in  the  interior  of  the  country, 
the  Mississippi  Valley,  and  the  southern  portion  of  the  Western 
Territories,  malarial  fevers  are  among  the  most  prevalent  camp 
diseases.  Greater  attention  in  locating  camps,  and  care  devoted 
to  draining  the  subsoil  and  maintaining  a  low  level  of  the  ground- 


256  TEXT-BOOK    OF    HYGIENE. 

water,  would  doubtless  result  in  improvement  in  the  sickness- 
rate  from  this  cause  in  the  army. 

Typhoid  Fever. — Typhoid  fever  is  prevalent  in  camps  and 
garrisons.  As  it  may  be  propagated  through  the  medium  of 
infected  discharges  of  typhoid  patients,  it  will  readily  be  perceived 
that  neglect  of  the  precaution  of  promptly  disinfecting  such  dis- 
charges will  almost  inevitably  result  in  spreading  the  disease, 
either  by  direct  inhalation  of  effluvia  from  the  patient  or  excreta, 
of  pollution  of  the  drinking-water,  or  by  contamination  of  the 
soil,  and  subsequently  of  the  atmosphere,  by  the  intestinal  dis- 
charges of  the  patient. 

Phthisis. — Especially  among  troops  in  barracks  phthisis  is 
a  very  fatal  disease.  Formerly  the  mortality  from  it  was  very 
heavy.  Recent  improvements  in  the  hygiene  of  military  posts 
and  greater  care  in  selecting  recruits  have  very  greatly  diminished 
the  death-rate  from  phthisis  among  soldiers.  Acute  pulmonary 
affections,  such  as  bronchitis,  pleurisy,  and  pneumonia,  are  com- 
paratively frequent  in  camps,  being  due  to  exposure. 

Typhus  Fever  and  Scurvy. — These  two  diseases  are  at  the 
present  day  comparatively  rare  as  camp  diseases.  They  break 
out,  however,  on  every  occasion  when  the  laws  of  hygiene  are 
violated  by  permitting  overcrowding,  overwork,  and  underfeeding. 
This  is  almost  certain  to  occur  during  war,  and  hence  either 
fully-developed  scurvy  or  a  scorbutic  taint  are  almost  constant 
accompaniments  of  an  army  in  the  field.  Among  the  allied  armies 
in  the  Crimea,  and  in  the  Federal  army  during  the  war,  scurvy 
and  typhus  fever  claimed  a  considerable  share  in  the  mortality. 

Purulent  Conjunctivitis. — This  affection  of  the  eyes  is  fre- 
quent among  soldiers.  It  has  even  been  supposed  to  be  peculiar 
to  soldier  life,  and  has  hence  been  termed  "  military  ophthalmia." 
It  is  contagious,  and  is  probably  most  often  spread  b'y  the  use 
of  basins  and  towels  in  common.  It  is  not  merely  annoying, 
but  is  a  very  grave  affection,  often  causing  perforation  of  the 
cornea  and  destruction  of  vision.  The  military  surgeon  should 
be  on  the  lookout  for  it,  and  promptly  isolate  those  infected. 


CAMP   DISEASES.  257 

Venereal  Diseases. — The  contagious  diseases  of  the  sexual 
organs  are  a  veritable  scourge  of  the  soldier's  life.  The  history 
of  these  diseases  is  intimately  interwoven  with  the  history  of 
armies,  camps,  and  wars.  The  first  wide-spread  appearance 
of  syphilis  in  the  fifteenth  century  is  coincident  with  the  siege 
of  Naples  by  the  French  army  under  Charles  VIII.1  It  has 
since  that  time  been  a  constant  companion  of  the  soldier  in  peace 
or  war,  and  in  all  seasons  and  countries.  Some  progress  toward 
its  restriction  has,  however,  been  made  in  recent  years  in  certain 
localities,  but  there  is  still  wide  room  for  improvement. 

In  1867  the  venereal  diseases  reported  in  the  Prussian  army 
were  53.9  per  1000  of  mean  strength.  In  1882  this  number 
had  been  reduced  to  41  per  1000,  in  1883  to  36.4,  and  in  1884 
to  32.8  per  1000.  In  the  Austrian  army  there  were  81  pei 
1000  in  1870,  diminishing  to  73.5  per  1000  in  1884.  In  the 
British  army  the  ravages  of  the  venereal  diseases  were  so  terrible 
that  legal  measures  for  their  restriction  by  subjecting  prostitutes 
to  inspection  were  taken.  In  1859  the  proportion  of  venereal 
disease  among  the  home  troops  was  400  per  1000.  In  1864 
and  1866  the  passage  and  enforcement  of  the  "Contagious  Dis- 
eases Act  "  caused  a  marked  diminution  of  these  diseases.  This 
reduction  is  particularly  noticeable  in  syphilis.  The  following 
table  gives  a  comparative  view  of  the  number  of  cases  of  syphilis 
per  1000  in  the  naval  service  at  ports  under  the  acts,  and  at 
ports  where  the  acts  were  not  enforced: — 

TABLE  XXIII. 

Ports  Under  the  Acts.  Ports  Not  Under  the  Acts. 

1860-1863  (no  restriction),  75.02  per  1000  70.50  per  1000 

1864-1865  (acts  enforced),  79.12    "       "  100.00   "       " 

1866-1870  (acts  extended),  47.19    "       "  84.74   "       " 

1871-1880,.         .         .         .  40.64    "       "  99.35   "       " 

In  the  French  army  the  proportion  of  venereal  diseases  was 
53  per  1000  from  1862  to  1866.  In  1867  the  proportion  in- 
creased to  106  per  1000.  This  increase  was  attributed  to  the 

1  See  article  on  Syphilis,  Chapter  XIX. 
17 


258  TEXT-BOOK   OF   HYGIENE. 

infection  during  the  Mexican  campaign.  In  1879  the  propor- 
tion had  again  diminished  to  65.9  per  1000. 

In  the  United  States  Army  the  venereal  diseases  numbered 
63  per  1000  among  the  white  and  81  per  1000  among  the 
colored  troops  in  1884.  A  chart  drawn  by  Major  Charles 
Smart,  surgeon  United  States  army,1  shows  in  an  interesting 
manner  how  opportunity  for  infection  influences  the  increase  of 
venereal  disease.  At  the  breaking  out  of  the  war,  when  large 
numbers  of  men  enlisted,  the  record  shows  a  rapid  increase  of 
venereal.  When  the  armies  were  in  the  field,  and  opportunities 
for  the  pursuit  of  Venus  were  few,  the  proportion  of  venereal 
decreased.  At  the  expiration  of  the  first  triennial  period  of 
enlistment,  the  soldier  with  his  final  pay  and  thirty  days'  fur- 
lough crowded  the  cities,  and  entered  on  a  period  of  dissipation 
which  usually  sent  him  back  to  the  recruiting  officer  with  empty 
pockets  and  an  attack  of  gonorrhoea  or  syphilis.  At  this  time 
the  records  show  a  large  number  of  cases,  which  gradually 
diminished  until  the  end  of  the  war,  when  the  opportunities 
for  infection  preliminary  to  the  final  muster-out  crowded  the 
hospitals  once  more  with  venereal  cases. 

The  experience  with  the  Contagious  Diseases  Act  in  Eng- 
land points  out  the  true  way  to  limit  or  entirely  extirpate  this 
disease  among  the  military  and  naval  forces.  An  inspection  at 
regular  intervals  not  only  of  public  prostitutes,  but  also  of  the 
soldiers  themselves,  and  segregation  of  the  infected  in  hospitals 
until  the  infective  period  is  past,  will  do  more  to  limit  the 
spread  of  venereal  disease  than  all  other  preventive  measures, 
public  or  private,  put  together. 

VI. CIVILIAN  CAMPS. 

The  camps  of  civil  life,  whether  established  for  the  purpose 
of  furnishing  a  refuge  to  the  inhabitants  of  cities  invaded  by 
epidemic  diseases,  as  yellow  fever  or  cholera,  or  whether  for 
religious  purposes  (camp-meetings),  or  for  recreation  (hunting 

»  Medical  and  Surgical  Hiscory  of  the  War,  third  medical  volume. 


CIVILIAN   CAMPS.  259 

and  fishing  camps,  etc.),  should  be  organized  and  managed  on  the 
same  principles  as  the  military  camp.  The  site  should  be  selected 
with  judgment — a  clean,  dry  soil,  and  abundance  of  wood  and 
water  being  requisite  for  a  healthy  camp.  A  superintendent 
or  officer  of  the  day  should  be  appointed,  whose  duty  it  is  to 
carefully  inspect  the  camp  daily,  and  compel  the  prompt  removal 
of  all  filth  and  offal  from  the  immediate  vicinity.  Cleanliness 
of  person,  clothing,  and  household  is  as  important  while 
"  roughing  it "  in  camp  as  at  home.  Singularly,  this  is  very 
often  forgotten  by  very  intelligent  people. 

The  advantage  of  a  well-administered  refugee  camp  in  case 
of  yellow-fever  epidemics  has  been  clearly  shown  by  the  brilliant 
success  of  the  depopulation  of  Memphis  during  the  epidemic  of 
1879  and  of  various  Florida  cities  and  towns  in  1888.  These 
experiments  deserve  imitation. 

[The  following  works  on  Military  and  Camp  Hygiene 
should  be  studied  in  connection  with  this  chapter : — 

Smart,  The  Hygiene  of  Camps,  in  Buck's  Hygiene  and  Public 
Health,  vol.  ii. — Wolzendorff,  Armee  Krankheiten,  in  Realencyclopaedie 
d.  ges.  Heilk.,  Bd.  I,  p.  489. — Schuster,  Kasernen,  in  von  Pettenkofer 
und  Ziemssen's  Handbuch  der  Hygiene,  II  Th.,  2  Abth. — Cameron: 
Camps,  Depopulation  of  Memphis,  Epidemics  of  1878  and  1879.  Public 
Health,  vol.  v,  p.  152. — Frolich,  Militarmedicin. — Medical  and  Surgical 
History  of  the  War,  especially  the  second  and  third  medical  volumes. 
— Annual  Reports  of  the  Supervising  Surgeon-General  of  the  United 
States  Marine  Hospital  Service,  1888-9.] 


QUESTIONS   TO   CHAPTER  X. 
MILITARY  AND  CAMP  HYGIENE. 

What  subjects  may  be  considered  under  this  head  ?  Why  should 
an  army  be  composed  of  sound  and  healthy  individuals  ?  Who  should 
be  excluded  from  an  army  or  body  of  troops  ?  What  is  the  lowest  age 
at  which  recruits  should  be  enlisted?  What  the  highest  age?  What 
should  be  the  minimum  measurements  of  the  recruit?  Who  should 
make  the  physical  examination  of  the  latter  ? 

What  can  be  said  for  the  present  army  ration  of  the  United  States? 
In  what  is  it  excessive  and  in  what  deficient?  In  what  other  ways  is  it 
objectionable?  What  besides  insufficient  quantity  and  variety  of  food 
may  cause  digestive  disturbances  and  innutrition  in  camp? 

What  part  of  the  United  States  soldier's  clothing  at  present  is  most 
apt  to  cause  physical  discomfort?  What  change  might  be  made  to 
advantage  in  the  manner  of  carrying  the  extra  clothing  ?  How  is  it  now 
carried  ? 

What  usually  constitutes  the  dwelling  of  the  soldier  ?  What  is  a 
military  barrack,  and  what  is  its  general  plan  ?  What  are  the  special 
points  in  favor  of  the  Toilet  system' of  barrack  construction?  What  is 
to  be  said  about  the  location  of  barrack  lavatories,  kitchens,  and  dining- 
rooms,  sinks,  and  latrines  ?  On  what  kind  of  soil  should  barracks  be 
located  ? 

What  sort  of  tents  are  used  in  the  army  ?  What  are  the  advantages 
of  the  simple  shelter  tent  ?  What  may  take  the  place  of  tents  in  winter  ? 
What  is  of  the  first  importance  in  all  camps,  and  what  is  necessary  to 
secure  this  ? 

In  actual  war  what  relation  do  the  deaths  from  disease  bear  to  those 
from  injuries  received  in  battle  ?  What  are  the  most  fatal  diseases  of 
camp  life?  What  are  the  causes  leading  to  this  fact  ?  What  other  class 
of  diseases  is  especially  apt  to  be  frequent  among  soldiers?  What  effect 
has  the  malarial  poison  on  those  sick  with  other  diseases  ?  What  would 
lessen  the  prevalence  of  malarial  fevers  in  camp-life?  How  may  typhoid 
fever  be  propagated  in  camps  and  garrisons  ?  What  respiratory  diseases 
are  common  in  camps,  and  to  what  are  they  due?  What  two  diseases, 
formerly  common  in  camp-life,  are  now  rare?  What  affection  of  special 
sense  is  frequent  among  soldiers,  and  to  what  is  this  frequency  to  be 
attributed  ?  What  contagious  diseases  are  especially  associated  with 
the  soldier?  By  what  means  mny  their  spread  be  restricted? 

For  what  purposes  may  civilian  camps  be  instituted  ?  What  prin- 
ciples should  be  followed  in  organizing  and  maintaining  them  ?  What 
are  prime  requisites  ?  Who  should  be  in  charge  of  such  a  camp  ?  Of 
what  advantage  may  such  camps  be  in  case  of  epidemics  of  contagious 
diseases  ? 

(260) 


CHAPTER  XI. 

MARINE  HYGIENE. 

THE  melancholy  accounts  of  the  mortality  from  scurvy, 
dysentery,  and  typhus  fever,  which  were  formerly  a  part  of  the 
history  of  so  many  naval  and  passenger  vessels,  are  happily 
now  only  records  of  the  past.  Occasionally,  however,  careless- 
ness of  the  authorities,  or  of  those  responsible  for  the  safety  of 
people  who  "  go  down  to  the  sea  in  ships,"  results  in  an  out- 
break of  one  or  other  of  these  diseases  even  at  the  present  day. 
Thus,  for  the  fiscal  year  ending  June  30,  1882,  71  cases  of 
scurvy  and  purpura  were  reported  by  the  medical  officers  of 
the  Marine  Hospital  Service.  It  appears  that  only  in  one 
instance  (where  6  cases  of  scurvy  had  occurred  on  one  vessel) 
was  any  investigation  ordered.  A  most  superficial  investigation 
showed  that  the  law  relating  to  the  issue  of  lime-juice  had  been 
violated  by  the  master  of  the  vessel.  No  prosecution  resulted. 
Such  facts  indicate  that  laxness  in  the  enforcement  of  the  regu- 
lations expressly  made  to  prevent  this  fatal  disease  may  be  again 
followed  by  outbreaks  of  greater  or  less  gravity. 

I. THE   SAILOR   AND   HIS   HABITS. 

Although  the  sailor  of  the  present  day,  especially  in  the 
naval  service,  is  morally  and  intellectually  far  in  advance  of  the 
"  Jack  Tar  "  of  former  days,  his  life,  both  afloat  and  on  shore, 
leaves  much  to  be  desired  on  the  score  of  temperance,  chastity, 
and  purity  of  thought  and  speech.  The  life  of  a  sailor  in  the 
United  States  navy,  thirty-eight  years  ago,  is  thus  graphically 
described  by  Medical  Director  Albert  L.  Gihon1 :  "  She  was 
manned  by  a  motley  crew,  of  whom  Americans  were  a  minority, 

1  Thirty  Years  of  Sanitary  Progress  in  the  Navy  :  Annual  Address  by  the  President  to 
the  Naval  Medical  Society,  Washington,  1884. 

(261) 


262        *  TEXT-BOOK   OF   HYGIENE. 

and  Englishmen,  Irishmen,  Northmen,  and  '  Dagos '  constituted 
the  far  greater  part.  Some  had  just  returned  from  another  cruise, 
having  squandered  or  heen  robbed  of  their  three  years'  pay  by 
the  'landsharks',  who  cajoled  them,  only  half  sober,  to  the  ren- 
dezvous, to  be  reshipped,  and  thence  to  be  herded,  uncared  for, 
on  the  receiving-ship,  still  popularly  termed  the  '  guardo,'  until 
drafted  on  board  the  first  sea-going  vessel.  All  of  them  were  in 
debt,  most  of  them  insufficiently  clad,  and  unable  to  properly 
outfit  themselves.  The  wretched  herd,  who  were  thus  gathered 
from  the  purlieus  of  Water  Street,  and  North  Street,  and  South 
Street,  who  at  night  were  kenneled  worse  than  dogs,  by  day 
fed  like  them,  crouching  on  their  haunches  around  greasy 
mess-cloths,  cutting  with  jack-knives  or  pulling  to  pieces  with 
grimy  fingers  the  chunks  of  '  salt  horse'  and  'duff'  which 
made  their  daily  fare,  and  which,  later  in  the  cruise,  were  both 
spoiled  and  scanty,  did  not  constitute  an  elevating  subject  for 
contemplation. 

"  Stint  of  good  food,"  continues  Dr.  Gihon,  "was,  however, 
not  the  chief  of  the  old-time  '  shell-back's '  ocean  trials.  Fed 
like  a  brute,  housed  worse  than  one,  however  faithfully  his  labors 
were  performed,  there  was  for  him  only  a  long,  dreary  season 
of  imprisonment.  For  him  there  was  no  glad  holiday  on  shore, 
when  the  land  broke  the  monotony  of  the  waste  of  waters. 
The  officers  might  rush  pell-mell  out  of  the  ship,  but  Jack  could 
only  strain  his  longing  eyes  upon  the  green  fields  or  busy  sea- 
ports. Notwithstanding  the  hardships  of  the  voyage,  the 
wretched  food,  and  the  outbreaks  of  disease,  the  crew  were  con- 
fined eight  months  on  board  ship,  before  '  general  liberty '  was 
given,  and  then  men  and  boys  were  sent  on  shore  for  forty-eight 
hours  to  indulge  in  a  mad  revel,  and  to  return  crazed  by  rum, 
battered,  and  bruised.  The  poor  wretch,  first  made  ravenously 
hungry  for  dissipation  by  his  enforced  confinement,  was  then 
expected  to  be  temperate  in  the  feast  of  indulgence  offered  him, 
and  punished  with  vindictiveness  if  he  sought  to  gorge  himself 
with  the  poor  semblance  of  pleasure.  The  'cat'  had  been 


THE    SAILOR   AND   HIS   HABITS.  263 

abolished,  but  half  a  dozen  boys  strung  upon  the  poop  'bucked 
and  gagged ' ;  half  a  dozen  men  triced  up  by  their  thumbs  in 
the  rigging ;  each  of  the  upright  coffin-like  '  sweat-boxes'  with 
its  semi-asphyxiated  inmate ;  the  '  brig '  with  its  bruised  and 
bloated  crew  in  irons ;  the  main-hold  with  its  contingent  under 
hatches ;  the  sick-list  swollen  out  of  all  proportions  by  in- 
ebriates, injured  men,  and  venereal  cases ; — these  were  the  fruits 
of  the  *  general  liberty,'  which,  within  my  professional  life, 
represented  the  sum  of  sanitary  interest  in  the  man  before  the 
mast." 

Under  such  circumstances  little  could  be  hoped  for  in  the 
way  of  personal  advancement  of  the  crew.  The  labors,  how- 
ever, of  the  writer  just  quoted,  and  others,  among  whom  may 
be  mentioned  Wilson  and  Turner,  of  the  navy,  and  Wood  worth, 
Hebersmith,  and  Wyman,  of  the  Marine  Hospital  Service,  have 
drawn  prominent  attention  to  the  unsanitary  conditions  of  the 
sailor's  life,  and  legal  enactments  have  done  much  to  elevate 
him  to  his  proper  rank  as  a  human  being,  entitled  to  be  treated 
with  humanity,  at  least. 

The  seaman  in  the  navy  is  now  well  clad,  and  receives  an 
abundance  of  food,  of  good  quality,  usually  well  cooked  and 
decently  served.  "  Latrines  and  bath-  and  wash-  rooms  under 
the  top-gallant  forecastle ;  mess-tables  and  benches ;  mess- 
lockers  and  clothes-lockers ;  a  place  where,  and  opportunities 
when,  men  can  read  and  write ;  and  frequent  daily  liberty  to 
go  on  shore,  if  not  already  common  to  every  vessel,  are  yet  now 
so  generally  the  concomitants  of  the  well-officered  and  well-dis- 
ciplined and  efficient  ship,  that  ere  long  their  absence  will  be 
accounted  a  fault." *  A  medical  corps,  selected  after  the  most 
rigorous  examination  known  to  the  profession,  and  provided 
with  every  aid  and  appliance  of  medical  science,  cares  for  the 
enlisted  sailor  and  marine  when  ill  or  injured,  as  tenderly  as  for 
the  commissioned  officer. 

The  sailor  in  the  merchant  service,  however,  is  still  at  the 

1  Thirty  Years  of  Sanitary  Progress  in  the  Navy,  Gihon. 


264  TEXT-BOOK    OF    HYGIENE. 

mercy  of  inhuman  masters,  who  exact  excessive  service  in  return 
for  insufficient  food,  scanty  clothing,  miserable  lodging,  abuse, 
ill-treatment,  and  neglect  when  sick  or  disabled. 

II. THE   PASSENGER. 

During  the  ten  years  from  1870  to  1879,  inclusive,  passen- 
ger vessels  carried  1,561,126  passengers  from  foreign  ports  en 
route  to  New  York  City.  The  mean  duration  of  each  voyage 
was  13.5  days.  Out  of  the  above  number  of  passengers  2518 
died  on  the  voyage, — a  death-rate  of  1.61  per  1000  for  the 
voyage  and  43.5  per  1000  per  annum.  These  figures  accentuate 
the  importance  of  sanitary  improvement  in  passenger  vessels. 
The  causes  of  this  excessive  mortality  among  emigrants — for  it 
is  almost  exclusively  among  the  passengers  in  the  steerage,  or 
"  between  decks,"  that  the  deaths  occur — are  overcrowding,  im- 
proper feeding,  defective  ventilation,  filthy  personal  habits,  and 
inefficient  medical  attention  when  sick.  Although  overcrowd- 
ing is  prohibited  by  statute,  yet  in  every  emigrant  vessel  that 
arrived  in  New  York  during  the  first  nine  months  of  1880  the 
number  of  passengers  was  in  excess  of  the  number  allowed  by 
law.1  The  shorter  voyages  and  better  sanitary  conditions  ob- 
tainable since  steamships,  especially  those  built  of  iron,  have 
come  into  general  use  for  the  carriage  of  passengers,  have  very 
much  reduced  the  mortality  on  ocean  voyages ;  but,  as  just 
shown,  the  death-rate  is  still  excessively  high,  and  many  more  im- 
provements in  the  hygiene  of  emigrant  vessels  and  of  passengers 
are  desirable. 

III. THE    SHIP   AS   A   HABITATION. 

As  a  habitation  for  the  sailor  and  passenger  the  ship  de- 
mands the  attention  of  the  sanitarian.  The  principal  points  in 
which  he  is  interested  are  the  construction  and  ventilation  of 
sleeping-apartments,  and  the  means  of  keeping  the  entire  ship 
clean  and  free  of  water  and  impure  air. 

The  keel  is  the  foundation  of  the  ship.     Branching  out 

1  Hygiene  in  Emigrant  Ships,  Turner,  Public  Health,  vol.  vi,  p.  24. 


THE    SHIP   AS   A    HABITATION.  265 

transversely  from  it  are  curved  timbers,  the  ribs,  which,  with  the 
keel,  constitute  the  ship's  frame.  The  ribs  are  covered  exter- 
nally and  internally  with  planking,  and  the  spaces  between  the 
two  coverings  are  the  frame-spaces,  which  are  usually  partly 
filled  with  filthy  water,  decomposing  organic  matter,  and  foul 
air.  The  water  collects  in  the  bottom  of  the  vessel,  the  bilge,1 
whence  it  is  pumped  out  of  the  vessel.  If  the  pumping  is 
neglected  the  bilge-water  becomes  very  offensive,  and  may  cause 
disease  in  persons  exposed  to  exhalations  from  it.  The  frame- 
spaces  are  rarely  ventilated,  and  hence  are  frequent  sources  of 
pollution  of  air  on  board  vessels. 

The  sleeping-apartment  of  the  crew  of  a  merchant  vessel 
is  in  the  forecastle,  usually  a  small,  dark,  damp,  filthy,  un ven- 
tilated space  in  the  bow  of  the  vessel,  where  they  are  kenneled 
like  brutes.  On  naval  vessels  the  crews  sleep  on  the  berth- 
deck,  which,  in  the  rarest  instances,  is  properly  lighted  and 
ventilated.  The  berth-deck  is  usually  below  the  water-line. 
In  nearly  all  and  even  the  best  class  of  vessels  in  the  United 
States  navy  the  air-allowance  for  each  man  is  less  than  3  cubic 
metres,  rarely  reaches  4,  is  oftener  from  2  to  2^,  and  is  some- 
times as  low  as  1  cubic  metre.  The  men  swing  by  night  in 
hammocks  suspended  from  the  beams  overhead,  and  removed 
when  not  in  use,  carried  on  deck,  and  stored  in  lockers,  called 
"hammock-nettings,"  on  the  ship's  sides. 

That  a  ship  should,  above  all,  be  seaworthy  would  seem  to 
require  no  argument.  It  is  self-evident  that  a  leaky  or  rotten 
ship  is  at  all  times  a  highly  dangerous  habitation,  yet  crews  and 
passengers  are  almost  daily  exposed  to  the  perils  of  shipwreck 
in  unseaworthy  vessels,  especially  in  the  mercantile  marine.2 

"Dampness,  dirt,  foul  air,  and  darkness,"  according  to 
Gihon,  "  are  the  direst  enemies  with  which  the  sailor  has  to 
battle  when  afloat."3  The  first  requisite  for  a  healthy  ship  is 

1  Hence  called  "bilge- water." 

2  The  Safety  of  Ships  and  Those  who  Travel  in  Them,  Woodworth,  Public  Health, 
vol.  iii,  p.  79  et  seq. 

*  Naval  Hygiene,  3d  ed.,  p.  28. 


266  TEXT-BOOK   OF   HYGIENE. 

dryness.  "A  damp  ship  is  an  unhealthy  ship,"  says  Fonssa- 
grives,  the  greatest  authority  on  naval  hygiene.  From  official 
reports  it  appears  that  the  relative  humidity  of  the  berth-deck 
of  vessels  in  the  United  States  navy  is  nearly  always  above  80 
per  cent.,  very  often  rising  to  90  and  95  per  cent.1  From  the 
same  source  it  is  learned  that  the  class  of  respiratory  diseases 
furnished,  with  one  exception,  the  largest  amount  of  sickness  in 
the  navy  during  the  year  1880.  It  is  the  concurrent  testimony 
of  all  authorities  in  marine  hygiene  that  the  vicious  custom  of 
daily  drenching  the  decks  with  water,  under  the  plea  of  cleanli- 
ness, is  mainly  responsible  for  this  excessive  moisture  and  its 
results.  The  battle  of  naval  hygiene  was  long  fought  on  this 
contested  field  of  wet  decks,  until  the  fact  became  so  patent  that 
wet  ships  were  always  unhealthy  ones.  It  is,  therefore,  one 
of  the  most  important  aims  of  marine  hygiene  to  curtail  this 
practice. 

Gihon  recommends  that  the  decks  be  painted  and  then 
coated  with  shellac,  occasionally  renewed,  to  make  them  non- 
absorbent,  and  to  wet  them  as  rarely  as  possible,  consistent  with 
cleanliness,  the  smooth  surface  of  the  shellacked  deck  being 
quickly  swabbed  over  with  hot  water  and  thoroughly  dried. 

The  ship  should  be  clean  and  well  ventilated.  Efforts  to 
keep  a  ship  clean  should  not  be  expended  upon  the  decks  only; 
the  occupied  apartments  below  the  hatches,  the  bilges  and  frame- 
spaces  should  all  receive  especial  attention  from  the  sanitary 
inspector. 

It  is  quite  frequently  necessary  to  remove  the  flooring  of 
the  vessels  in  order  to  expose  the  accumulations  of  filth,  which 
often  make  an  infected  ship  synonymous  with  a  dirty  ship.  An 
unobstructed  passage,  to  which  ready  access  can  be  had  through 
removable  covers,  should  extend  under  the  flooring  from  one 
end  of  the  vessel  to  the  other.  To  disinfect  a  dirty  ship,  steam 
forced  into  the  hold  under  pressure,  before  and  after  the  filth 
has  been  cleaned  out,  gives  the  most  satisfactory  results. 

1  Report  of  Surgeon-General  of  the  Navy,  Washington,  1880. 


THE    SHIP   AS    A    HABITATION.  267 

Chlorine  and  fumes  of  sulphur  burned  in  the  presence  of  watery 
vapor  are  next  in  efficiency.1  Solutions  of  sulphate  of  iron 
or  chloride  of  zinc  may  be  poured  into  the  bilges  to  prevent 
decomposition. 

It  has  been  estimated2  that  a  minimum  of  15  cubic  metres 
of  air-space,  with  facilities  for  thorough  ventilation,  should  be 
allowed  to  each  person  on  board  ship.  It  is  safe  to  say  that  no 
vessel  that  floats  gives  to  her  passengers  or  crew  the  advantages 
of  such  conditions.  Ventilation  of  the  holds  and  bilges,  and  of 
the  spaces  between  the  frames  or  ribs, — "  intercostal  ventilation," 
as  Turner  calls  it, — is  especially  necessary.  Any  system  of  ven- 
tilation that  does  not  contemplate  the  removal  of  the  foul 
bilge-air  is  unworthy  of  consideration  by  the  sanitarian.  The 
ventilating  apparatus  which  has  been  introduced  on  board  the 
modern  vessels  of  the  United  States  navy  consists  essentially  of 
longitudinal  mains  extending^through  the  entire  length  of  the 
ship,  connecting  with  powerful  fan-blowers  usually  located  on 
the  berth-deck  nearly  amidships.  In  large  vessels  four  blowers 
are  fitted,  each  being  connected  with  an  independent  system  of 
pipes  and  all  fitted  with  reversible  valves,  so  that  they  may  be 
used  either  for  exhausting  foul  air  or  supplying  fresh,  and  also 
fitted  so  that  the  fan  systems  can  be  used  in  combination,  thus 
simultaneously  exhausting  foul  air  from  and  supplying  fresh 
air  to  any  compartment  in  the  vessel.  These  blowers  are 
driven  at  about  four  hundred  revolutions  per  minute  and  are  of 
sufficient  power  to  maintain  a  vacuum  of  a  half-inch  below  the 
atmosphere  throughout  the  entire  systems  of  pipes.  Small 
metal  pipes  connect  these  longitudinal  mains  with  every  state- 
room, store-room,  pantry,  and  other  inclosed  apartment  on  the 
berth-deck,  orlop,  and  holds.  All  the  openings  in  these  pipes 
are  bell-mouthed  and  fitted  with  wire  gauze  and  registers,  with 
a  clear  opening  equal  to  twice  the  area  of  the  pipe.  Additional 
ventilating  pipes  are  led  from  the  bilges,  wherever  necessary,  up 

1  Report  of  Committee  on  Disinfectants,  American  Public  Health  Association. 
3  "Hygiene  of  Emigrant  Ships,"  Public  Health,  vol.  vi,  p.  26. 


268  TEXT-BOOK   OP    HYGIENE. 

the  sides  of  the  vessel,  terminating  in  brass  louvres  inside  the 
bulwarks,  these  being  also  fitted  with  additional  louvres  between 
decks,  especial  care  being  taken  to  prevent  the  foul  air  from  the 
bilges  thereby  reaching  the  living-spaces. 

Fresh  air  finds  its  way  below  through  the  wind-sails,  venti- 
lating-shafts,  hatchways,  and  air-ports,  entering  the  apartments 
by  way  of  doors,  crevices,  and  other  natural  apertures.  The 
absolutely  essential  condition  of  this  system  of  ventilation  is  that 
the  blowers  shall  revolve,  but,  unfortunately,  sanitary  interests 
are  too  often  sacrificed  on  the  pretext  that  economy  of  fuel  will 
not  permit  the  operation  of  the  fan.1 

All  parts  of  the  vessel  used  as  habitations  or  sleeping- 
apartments  should  receive  sufficient  sunlight.  At  present,  very 
few  vessels  have  the  quarters  of  the  crew  so  disposed  as  to  admit 
any  sunshine  at  all. 

In  the  fire-rooms  of  steam-ships,  especially  on  that  class  of 
naval  vessels  termed  monitors,  the  temperature  often  rises  so 
high  as  would  seem  to  render  continued  existence  in  it  impos- 
sible. Gihou  states  that  the  average  temperature  in  the  fire- 
room  of  the  monitor  Dictator  was  145°  F.  (63°  C.),  while 
Turner  states  that  in  another  vessel  the  average  fire-room  tem- 
perature was  167°  F.  (75°  C.).2  The  firemen  and  coal-heavers 
(stokers)  frequently  suffer  from  heat-stroke,  and,  in  a  very  large 
proportion  of  cases,  from  heart  disease. 

Lavatories  and  bathing  facilities  should  be  furnished  on 
vessels  for  passengers  and  crew,  and  both  should  be  compelled 
to  keep  their  bodies  and  clothing  clean.  A  more  liberal  supply 
of  water  for  drinking,  a  more  frequent  issue  of  fresh  meat  and 
vegetables,  and  better  cooking  are  the  sanitary  considerations 
to-day  in  the  subsistence  of  the  sailor.  The  American  naval 
ration  is  superior  in  variety,  nutrient  value,  and  palatableness- 
to  that  of  any  foreign  service;  but  skilled  cooks  are  still  a  de- 
sideratum on  board  men-of-war,  and  medical  officers  have  Ions: 

O 

been  insisting  that  schools  for  their  instruction  should  be  estab- 

1  Hygiene  (Naval),  Hnnd-lionk  of  the  Medical  Sciences,  Gihon. 
*  Buck's  Hygiene  and  Public  Health,  vol.  ii,  p.  190. 


THE    SHIP   AS   A    HABITATION. 


269 


lished  at  recruiting  stations.     The  composition  and  distribution 
of  the  rations  are  given  in  the  following  table : — 

TABLE  XXIV. 
ALLOWANCE  FOB  GENERAL  DAILY  USE. 

(Either  one  of  the  following.) 


Rations  Established 
by  Law. 


Specified  by  Law. 


Substitutes  Authorized  by  Law. 


Ration  No.  1  . 


Ration  No.  2 


Ration  No.  3  . 


Ration  No.  4  . 


1  lb.  salt  pork .... 
£  pint  beans  or  peas  . 

1  lb.  salt  beef  .... 
£  lb.  flour 

2  oz.  dried  fruit  . 


£  lb.  preserved  meat    . 

|  lb.  rice  

2  oz.  butter         .    . 

1  oz.    desiccated    mixed 
vegetables 1 

£  lb.    preserved  meat  .    . 

2  oz.  butter  ...... 

6  oz.  desiccated  tomatoes  1 


li  lb.  fresh  meat ;  or, 
1  lb.  preserved  meat. 
Vegetables  of  equal  value  ;  or, 
£  lb.  rice. 

1^  lb.  fresh  meat ;  or, 
A  lb.  preserved  meat. 
Vegetables  of  equal  value. 

No  substitute. 

A  pint  beans  or  peas. 

No  substitute. 

6  oz.  canned  vegetables. 

No  substitute. 
No  substitute. 
6  oz.  canned  tomatoes. 


DAILY    ALLOWANCE. 


Specified  by  Law. 

Substitutes  Authorized  by  Law. 

1  lb.  soft  bread. 
1  lb.  flour. 
£  lb.  rice. 

2  oz.  coffee. 
2  oz.  cocoa. 

For  coffee  and  sugar,  extract  of  coffee 
combined  with  milk  and  sugar  may 
be  substituted  by  the  Secretary  of  the 
Navy,  if  not  more  expensive. 

^  oz.  tea  < 

4  oz.  sugar     

WEEKLY    ALLOWANCE. 


Specified  by  Law. 


Substitutes  Authorized  by  Law. 


pint  pickles  2. 
pint  molasses 
pint  vinegar  . 


None. 
None. 
None. 


1  These  articles  being  out  of  the  market,  and,  not  procurable,  the  nearest  possible  sub- 
stitutes arc  Riven. 

a  One-half  pint  pickles  is  considered  equal  to  one-half  pound,  and  is  issued  as  such. 


270 


TEXT-BOOK   OF    HYGIENE. 


The  substitutes  authorized  by  law  permit  nine  variations 
of  ration  No.  1,  six  of  ration  No.  2,  three  of  ration  No.  3,  and 
two  of  ration  No.  4. 

The  quantity  of  fresh  vegetables  authorized  is  to  be  equal 
in  value  to  any  or  all  of  the  articles  usually  issued  with  the 
salted  meats,  for  which  they  may  be  substituted,  the  allowance 
fixed  for  issue  being  one  and  one-fourth  pounds  per  ration. 

Dried  fruit  may  be  either  dried  apples,  peaches,  raisins, 
currants,  prunes,  figs,  dates,  or  any  other  dried  fruit. 

Preserved  meat  comprises  roast  or  compressed  beef,  Chi- 
cago corned  beef,  fresh  mutton,  or  any  other  canned  preserved 
meat,  ham,  brawn,  bacon,  sausage,  salt  fish,  and  any  other  salted 
or  smoked  preserved  meat. 

In  addition  to  these,  the  daily  allowance  of  fourteen  ounces 

TABLE  XXV. 

UNITED  STATES  NAVY  SEA-  OK  SALT-  RATION.    ONE  WEEK'S  ISSUE. 


ARTICLES. 

ALLOWANCE. 

NUTRIENTS  IK  GRAMMES. 

Mineral 
Matters. 

•33* 

S&S 
®  •—  a 

Isl 

faH» 

Lb. 

Oz. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Salt  pork  *  .    . 

2 
1 
4 
1 

2 

8 
8 

2 
4 
6 
12 
8 
6 
8 
1.50 

194.14 
115.78 
231  33 
13.77 
16.78 
60.55 
10478 
49.89 
433.41 
2.72 
1.70 

52.05 
0.78 
69.40 
2.04 
0.90 

3&T 

9.07 
4.98 
36.11 

144.58 

66.33 
180.07 
127.91 
270.53 
339.74 
2039.27 
70.30 
0.85 
776.33 
165.79 

163.57 
82.0 
32.16 

0.90 
6.57 
14.06 
2.26 
24.23 

5.10 

Salt  beef  1    .    .    . 
Preserved  meats  2  .   . 
Canned  vegetables  . 
Rice  3    

Beans       

1 
1 
6 

Flour  3  

Biscuit      

Dried  fruit  

Butter  

Sugar    

1 

Molasses  

Cocoa   

Coffee   

Tea    

Vinegar  and  pickles. 

1 

Total  

22 

1.50 

1224.85 

323.76 

4037.12 

330.85 

Daily  average    .    . 

8 

0.35 

174.98 

4625 

576.71 

47.26 

3515 

1  Eighteen  per  cent,  waste. 

9  Corned  beef,  roast  beef,  and  sausage  meat. 

Substitutes :  Ham,  brawn,  bacon,  smoked  and  salt  fish. 
1  Or  cornmeal,  hominy,  oatmeal. 


DISEASES   ON    SHIPBOARD. 


271 


TABLE  XXVI. 
UNITED  STATES  NAVY  FRESH  RATION.    AVERAGE  DAILY  ISSUE. 


ARTICLES. 

ALLOWANCE. 

NUTRIENTS  IN  GRAMMES. 

Mineral 
Matters. 

Potential 
Energy  in 
Calories. 

Lb. 

Oz. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Fresh   meats  *    ... 
Fresh  vegetables  2    . 
Fresh  bread   .... 
Flour    

1 

1 
1 

4.0 
4.0 

228 
0.85 
4.0 

87.68 
10.71 
37.71 
7.12 
0.08 

7448 
0.43 
7.71 
0.72 
21.99 

74.19 
2o5.37 

48.53 

110.90 

23.80 
10.04 

4.35 
4.08 
3.98 
0.32 
0.22 

Butter      

Sugar        

Molasses  
Dried  fruit         .   .    . 

1.14 
0.57 
0.85 
1.14 
0.18 
2.28 

0.39 

Cocoa    

Coffee       

Tea    

Pickles  and  vinegar. 

Total.       .       .    . 

4 

5.29 

143.69 

105.33 

522.83 

12.95 

3715 

THE  DAILY  AVERAGE  UNITED  STATES  NAVAL  RATION. 


The  mean  of  all  food-supplies 


r  Protein 157.34 

Fats 75.59 

Carbohydrates 549.77 

Mineral  matters  30. 10 

Potential  energy  in  calories  .  .  .  3615 

.  Potential  energy  in  foot  tons  .    .    .    5531 


of  biscuit  can  be  varied  by  tbe  substitution  of  one  pound  of  soft 
bread,  or  one  pound  of  flour  (which  may  be  either  wheat,  rye, 
cornmeal,  oatmeal,  or  hominy),  or  one-half  pound  of  rice.3 

Surgeon  Charles  A.  Siegfried,  of  the  United  States  navy, 
has  tabulated  the  American  naval  ration  according  to  its  nutrient 
value.4  (See  Tables  XXV  and  XXVI.) 

IV. DISEASES   ON    SHIPBOARD. 

The  diseases  most  liable  to  attack  persons  on  shipboard 
are:  Diseases  of  the  respiratory  organs,  rheumatism, .malarial 
diseases,  digestive  disorders,  scurvy,  typhus  fever,  and  skin 
diseases ;  and,  where  the  infection  has  been  conveyed  to  the 

1  Twenty  per  cent,  waste.    Calculated  from  total  fore  and  hind  quarters. 

3  Eighteen  per  cent,  waste.    Potatoes,  onions,  cabbage,  etc.,  mixed. 
*  U.  S.  Navy  Ration  Regulations,  1884. 

4  Journal  of  American  Medical  A-ssociation,  December  31, 1892. 


212  TEXT-BOOK  OF  HYGIENE. 

vessel  by  other  persons  or  by  fomites,  yellow  fever,  cholera, 
small-pox,  and  venereal  diseases.  It  is  interesting  to  note,  in 
a  recent  report  of  the  Surgeon-General  of  the  Navy,  that,  among 
a  total  of  8550  admissions  of  sick  and  disabled  officers  and 
men  of  the  navy  and  marine  service,  nearly  90  per  cent,  were 
included  in  the  following  classes,  to  wit : — 

Casualties, 1911 

Affections  of  the  respiratory  tract,     .         .         .  1149 

Venereal  diseases, 1071 

Malarial  and  other  fevers, 888 

Diseases  of  the  integument,         ....  888 

Rheumatism,        .......  521 

Affections  of  the  nervous  system,       .         .         .  489 

Diarrhceal  maladies, 483 

The  remaining  1144  were  distributed  over  a  wide  range  of 
titles,  of  which  many,  as  adynamia,  cephalalgia,  constipation, 
odontalgia,  etc.,  have  no  special  pathological  significance.  It  is 
probable  that  only  about  one-fourth  of  the  cases  of  disease 
occurring  at  sea  are  attributable  to  any  of  the  circumstances  of 
oceanic  life,  and  these  are  almost  entirely  inflammatory  affections 
of  the  air-passages  and  intestinal  tract,  neuroses,  including 
nausea  marina,  and  rheumatism.1 

Most  of  these  affections  can  be  prevented  by  proper  meas- 
ures of  hvgiene,  as  demanded  bv  the  conditions  described  in  this 

•/  o  •/ 

chapter  or  by  the  enforcement  of  the  following  regulations : — 

Inspection  of  crews  and  passengers  should  be  made  com- 
pirlsory  before  shipment.  Persons  suffering  from  contagious  or 
infectious  diseases  should  not  be  taken  on  board.2  In  order  to 
make  this  provision  effective,  the  history  of  the  individual  for 
two  weeks  prior  to  his  application  for  shipment  should  be  known 
to  the  inspecting  officer.  Passengers  should  possess  bills  of 
health  from  the  local  authorities  at  their  homes,  in  order  that 

1  "The  Therapy  of  Ocean  Climate,"  Gihon,  Transactions  of  American  Climatological 
Association,  1889. 

1  Gihon  relates  an  instance  where  a  man  suffering  from  parotitis  was  transferred  from 
the  hospital  of  a,  receiving-ship  to  a  vessel  going  to  sea.  The  disease  was  communicated  to 
more  than  seventy  of  the  crew  of  the  latter  vessel. 


DISEASES   ON   SHIPBOARD.  273 

the  presence  or  absence  of  such  diseases  as  small-pox,  yellow 
fever,  cholera,  or  plague  may  be  established  by  the  inspector. 
Cholera  has  always  been  introduced  into  this  country  by  immi- 
grants. Everybody  admitted  to  the  ship  should  be  vaccinated. 
During  several  years  past  a  number  of  epidemics  of  small-pox 
have  been  traced  to  foreign  immigrants  who  had  not  been 
properly  vaccinated. 

Sailors  in  the  merchant  service  should,  like  those  in  the 
navy,  be  submitted  to  a  close  personal  inspection,  and  those 
suffering  from  venereal  diseases  should  be  rejected.  The  usual 
history  of  the  cases  is  that  they  soon .  go  on  the  sick-list,  and 
thus  become  an  incumbrance  instead  of  an  aid  on  the  vessel. 
Statistics  show  that  1  man  in  every  7  or  8  in  the  naval  service 
and  1  in  every  4  of  the  crews  of  merchant  vessels  are  affected 
with  some  form  of  venereal  malady.1  These  inspections  should 
not  be  restricted  to  examinations  for  venereal  diseases,  but  indi- 
viduals incapacitated  for  the  performance  of  a  seaman's  duties 
by  any  cause  should  be  rejected.  This  precaution  would  un- 
questionably reduce  the  number  of  marine  disasters  directly 
traceable  to  deficiency  in  the  working  force  on  board  vessels. 
In  this  country  the  services  of  the  medical  officers  of  the  Marine- 
Hospital  Service  might  be  made  available  to  carry  out  these 
inspections. 

All  sailors  are  liable  to  be  placed  in  positions  where  the 
prompt  and  accurate  distinction  of  colors  becomes  necessary; 
hence  all  color-blind  individuals  should  be  rejected  as  seamen. 
The  inability  to  distinguish  colors  has  often  been  the  cause  of 
grave  accidents  at  sea.  Pilots  can  no  longer  obtain  a  license 
unless  they  satisfactorily  pass  an  examination  with  reference  to 
their  ability  to  distinguish  colors. 

The  protection  of  the  passenger  on  shipboard,  as  well  as 
the  safeguarding  of  a  country  against  the  introduction  of 
exotic  epidemic  diseases,  demands  that  the  sanitary  and  medical 
service  on  board  emigrant  ships  shall  be  the  best  attainable. 

1  "The  Prevention  of  Venereal  Diseases,"  Gilion,  Public  Health,  1882. 

18 


274  TEXT-BOOK   OF   HYGIENE. 

At  present  there  are  still  many  short-comings.  A  recent  report 
made  to  the  American  Public  Health  Association,  by  a  com- 
mittee appointed  for  the  purpose,  gives  an  authoritative  ex- 
pression of  opinion  upon  these  points.  The  committee  advise : 

"1.  As  to  the  location  and  dimensions  of  the  quarters  for 
emigrant  passengers,  the  number  of  berths  in  each,  and  the 
provisions  for  their  ventilation  and  cleansing : 

"  That  the  preferable  location  for  such  quarters  is  abaft  the 
midship  section  of  the  vessel ;  that  single  males'  quarters  shall 
be  distinct  from  those  occupied  by  women  and  children,  and 
that,  if  any  are  forward  the  midship  section,  it  shall  be  those  for 
single  men. 

"  That  there  shall  never  be  more  than  two  decks  (properly 
there  should  be  only  one)  occupied  by  emigrant  passengers' 
berths,  with  sixteen  feet  of  superficial  space  for  each  adult  on 
the  upper  berth-deck  and  twenty  feet  of  such  space  on  the 
lower  berth-deck,  with  not  more  than  two  tiers  of  berths  on 
each  deck,  the  bottom  of  the  lower  tier  being  not  less  than 
eighteen  inches  above  the  deck,  with  not  less  than  thirty 
inches  between  the  two  tiers  and  between  the  upper  tier  and 
the  ceiling  of  the  compartment,  to  allow  the  occupants  of  the 
berths  to  sit  upright. 

"That  no  solid  partitions  or  bulkheads  shall  be  placed  in 
any  steerage  compartment  to  obstruct  light  and  air. 

"That  the  frame-work  of  the  berths  shall  be  of  iron,  easily 
removable,  that  the  compartment  may  be  completely  emptied 
and  thoroughly  cleaned  after  each  passage. 

"  That  a  steam  ventilating  apparatus  by  aspiration  shall  be 
introduced  into  all  emigrant  vessels  ;  and 

"  That  all  compartments  occupied  by  passengers  and  crew 
shall  be  lighted  by  the  incandescent  electric  light  by  night  and 
by  day. 

"  2.  As  to  the   location  and  dimensions  of  hospitals  on 
board  such  vessels  and   the  number  of  sick-berths  for  which, 
provision  should  be  made : 


DISEASES   ON   SHIPBOARD.  275 

"  That  the  hospitals,  or  '  sick-bays,'  on  board  emigrant  pas- 
senger vessels  shall  be  at  the  extreme  after  part  of  the  upper 
deck,  thoroughly  lighted  and  ventilated,  with  eighteen  feet  of 
superficial  space  for  every  fifty  passengers,  and  not  less  than 
four  sick-berths  or  hospital  cots  for  every  hundred  passengers. 

"  3.  As  to  the  number  of  medical  officers  proper  for  the 
maximum  of  emigrant  passengers  any  vessel  should  be  per- 
mitted to  carry,  being  the  maximum  number  able  to  be  berthed 
with  regard  to  health,  cleanliness,  and  comfort: 

"That  there  should  be  one  duly-qualified  medical  officer 
for  every  two  hundred  and  fifty  passengers. 

"  4.  As  to  the  professional  records  which  the  senior  medical 
officer  of  every  such  vessel  should  be  required  to  keep,  and  his 
responsibility  to  the  health  authorities  of  the  port  of  arrival 
for  the  truthful  and  professionally-accurate  statements  of  such 
records : 

"  That  the  senior  medical  officer  of  every  such  vessel  shall 
be  required  to  keep  (1)  a  list  of  sick,  recording  in  a  bound  book, 
in  the  order  of  their  admission,  and  on  a  single  line,  the  name, 
sex,  age,  birthplace,  date  of  admission  to  treatment,  date  of 
death  or  discharge  from  treatment,  disease,  and  such  remarks 
as  may  be  necessary  to  enable  the  inspecting  medical  officer  at 
the  port  of  arrival  to  have  a  clear  and  complete  understanding 
of  the  case ;  (2)  a  medical  journal,  in  which  each  medical 
officer,  when  there  are  more  than  one,  shall  record  the  medical 
history,  including  symptoms  and  treatment  of  every  case,  to  be 
approved  and  signed  by  the  senior  medical  officer  at  the  close 
of  the  day's  record  ;  and  such  list  of  sick  and  medical  journal 
shall  be  submitted  to  the  health  authorities  of  the  port  of  arrival, 
and  the  accuracy  of  the  statements  in  such  records  shall  be 
established  by  oath,  and  penalties  for  perjury  shall  be  provided. 

"  5.  As  to  the  location  and  capacity  of  latrines  for  emigrant 
passengers : 

"That  the  latrines — shallow  troughs  with  a  continuous 
flow  of  salt  water — shall  be  on  the  upper  deck,  under  shelter, 


276  TEXT-BOOK   OF   HYGIENE. 

with  two  water-closet  seats  for  every  fifty  passengers,  with  a 
proportionate  number  for  women  and  children,  in  a  separate 
locality,  near  their  own  quarters,  inaccessible  to  men. 

"  6.  As  to  the  number  of  attendants  provided  for  such  pas- 
sengers, and  their  duties  as  to  policing  and  cleansing  emigrants' 
quarters : 

"  That  there  shall  be  not  less  than  one  berth-deck  attendant 
for  every  fifty  passengers,  female  attendants  in  the  same  propor- 
tion being  exclusively  assigned  to  the  quarters  for  women  and 
children. 

"  That  the  berth-decks  shall  be  thoroughly  cleansed  every 
morning  by  the  attendants,  never  wetted  in  rainy  or  damp 
weather,  when  they  shall  be  scraped,  swept,  and  freshly  sanded ; 
and  in  pleasant  weather  washed  with  hot  water  and  quickly 
dried,  the  passengers  being  sent  on  deck  during  the  operation. 

"  That  the  berth-deck  attendants  shall  be  on  duty  night 
and  day  in  rotation  by  regular  sea  watches,  and  the  attendants 
on  watch  required  to  remove  the  dejecta  of  seasick  passengers 
without  delay. 

"  That  benches  and  mess-tables  shall  be  provided,  and  the 
passengers'  food  be  distributed  by  the  berth-deck  attendants, 
who  shall  take  away  all  unused  food  and  carry  the  dishes  to 
the  pantry. 

"  7.  As  to  additional  provisions  for  the  personal  health, 
cleanliness,  and  comfort  of  emigrant  passengers: 

"  That  wash-rooms,  under  cover,  with  basins  supplied  with 
running  water,  shall  be  provided  on  the  upper  deck ;  those  for 
men  to  be  separate  from  those  intended  for  women  and  children. 

"  That  fresh  water  for  drinking  purposes  shall  be  provided 
in  each  compartment ;  and 

"  That  inexpensive  mattresses,  pillows, — these  to  be  service- 
able as  life-preservers, — and  blankets  shall  be  provided  for  emi- 
grant passengers,  the  mattresses  to  be  destroyed  after  each 
passage,  and  the  pillows  and  blankets  to  be  steamed  and 
washed  before  being  ag.ain  used." 


DISEASES   ON   SHIPBOARD.  277 

[The  following  works  contain  more  detailed  information 
upon  the  subject  treated  in  the  foregoing  chapter : — 

Albert  L.  Gihon,  Practical  Suggestions  in  Naval  Hygiene,  3d  ed., 
Washington,  1873. — T.  J.  Turner,  Hygiene  of  the  Naval  and  Merchant 
Marine. — Buck's  Hygiene  and  Public  Health,  vol.  ii. — Walter  Wj'inan, 
Hygiene  of  Steam-boats  on  the  Western  Rivers. — Report  of  Supervising 
Surgeon-General  M.  H.  Service  for  1882. — Annual  Reports  of  the  Surgeon- 
General  of  the  Navy  for  18t9,  1880,  and  1881.— Various  papers  by  J.  M. 
Woodworth,  Albert  L.  Gihon,  T.  J.  Turner,  Hebersmith,  and  A.  N.  Bell 
in  Public  Health,  vols.  i,  iii,  and  vi. — Hygiene,  Naval,  by  Albert  L.  Gihon, 
M.D.,  in  Reference  Hand-book  of  Medical  Sciences.] 


QUESTIONS   TO   CHAPTER  XI. 

MARINE  HYGIENE. 

What  is  meant  by  marine  hygiene  ?  In  what  respects  is  the  condi- 
tion of  the  sailor  in  the  United  States  navy  now  better  than  formerly  ? 
Is  the  merchant  sailor  as  fortunate  ? 

How  does  the  death-rate  on  passenger  vessels  compare  with  that  on 
shore  ?  What  are  some  of  the  causes  of  the  excessive  mortality  among 
steerage  passengers  ?  In  what  ways  can  these  causes  be  prevented  ? 

What  are  the  principal  points  about  a  ship  in  which  the  sanitarian  is 
interested  ?  What  tends  to  pollute  the  air  of  a  ship  ?  What  is  meant 
by  the  bilge  and  bilge-water  ?  By  the  frame-spaces  ? 

Where  are  the  sleeping  apartments  usually  of  a  merchant  crew  ? 
Of  a  naval  crew  ?  What  are  the  faults  of  each  ?  What  are  the  sailor's 
greatest  enemies  when  afloat?  What  is  the  first  requisite  for  a  health}' 
ship  ?  What  is  the  relatiye  humidity  of  the  berth-deck  in  most  United 
States  naval  vessels  ?  To  what  is  this  excessive  humidity  largely  due  ? 
How  might  this  be  avoided  ?  What  class  of  diseases  is  especially  preva- 
lent in  the  navy  ? 

How  else  may  the  sanitary  condition  of  a  vessel  be  improved  ?  What 
is  meant  by  a  clean  ship?  How  may  a  dirty  ship  be  disinfected  ?  Where 
is  ventilation  especially  necessary  on  a  vessel  ? 

What  amount  of  air-space  should  be  allowed  each  person  on  board 
ship  ?  Is  this  customarily  provided  for  ?  Describe  the  ventilating  appa- 
ratus of  vessels  of  the  United  States  navy.  Upon  what  does  the  efficacy 
of  this  depend,  and  in  what  respect  is  it  faulty  ?  Do  the  sleeping-apart- 
ments of  vessels  receive  sufficient  sunlight  ?  To  what  maladies  are  the 
firemen  and  coal-heavers  of  steam-vessels  subject?  What  other  con- 
siderations affect  the  health  of  the  sailor  ? 

What  are  some  of  the  diseases  most  liable  to  attack  persons  on  ship- 
board ?  What  is  the  probable  order  of  frequency  ?  What  proportion 
are  really  attributable  to  the  sea-life  ?  How  can  most  of  the  affections 
be  prevented  ?  What  hygienic  regulations  should  be  enforced  both  be- 
fore and  after  embarkation.  Why  ?  With  what  should  each  passenger 
be  provided?  What  sailors  should  be  rejected  and  not  enlisted?  What 
may  happen  if  this  course  is  not  followed  ?  What  officers  might  carry 
on  the  inspection  in  this  country  ? 

(278) 


CHAPTER  XII. 

PRISON  HYGIENE. 

ALTHOUGH  the  frightful  mortality  which  formerly  seemed  a 
necessary  accompaniment  of  the  life  of  the  convict  has  in  the 
past  half-century  markedly  diminished,  the  death-rate  among 
prisoners  is  still  very  greatly  in  excess  of  that  of  persons  of  the 
same  age  in  a  state  of  liberty. 

The  observations  and  labors  of  John  Howard,  the  self- 
sacrificing  philanthropist,  in  the  latter  half  of  the  last  century, 
and  of  Elizabeth  Fry,  in  the  first  half  of  the  present,  directed 
the  attention  of  legislators  to  the  necessity  of  reform  in  the  con- 
duct of  prisons  and  the  treatment  of  prisoners.  As  a  conse- 
quence of  the  labors  of  these  reformers,  the  principles  of  prison 
discipline  have  been  more  fully  developed  during  the  past  forty 
years  by  students  of  social  science  everywhere,  and  certain 
propositions  have  been  formulated,  which  govern,  to  a  greater 
or  less  degree,  legislation  upon  this  subject.  These  propositions 
are,  briefly,  as  follow : — 

Prisoners  must  be  properly  classified  according  to  the 
nature  of  their  crime  and  the  duration  of  imprisonment. 

The  two  sexes  must  be  strictly  separated,  and  no  oppor- 
tunity given  for  intermingling  while  in  the  prison. 

Female  prisoners  should  have  female  attendants  exclusively. 
Male  watchmen  or  other  attendants  should  not  be  allowed  in 
the  female  department  of  a  prison. 

All  prisoners  must  be  kept  employed  at  some  manual  labor, 
not  necessarily  for  profit,  but  as  an  agency  in  the  moral  reforma- 
tion of  the  convict. 

Punishments  for  infractions  of  discipline  must  not  be 
excessive. 

(279) 


280  TEXT-BOOK   OF    HYGIENE. 

Efforts  should  be  constantly  made  tending  to  the  reclama- 
tion of  criminals  from  their  life  of  sin  and  crime. 

Due  care  must  be  taken  by  the  State  to  preserve  the  health 
and  life  of  the  prisoner  whom  the  State  has  deprived  of  liberty 
and  the  opportunity  of  taking  care  of  himself. 

A  proper  classification  of  prisoners,  according  to  the  degree 
of  their  criminality,  the  nature  of  the  crime  of  which  they  have 
been  convicted,  or  the  length  of  time  for  which  they  have  been 
sentenced,  is  now  insisted  upon  by  all  students  of  prison  dis- 
cipline. As  this  subject  more  nearly  concerns  the  social  or  legal 
relations  of  prisoners  rather  than  their  sanitary  interests,  it  is 
here  passed  over  with  a  mere  mention. 

The  separation  of  the  sexes,  necessity  of  female  attendants 
on  prisoners  of  the  same  sex,  employment  of  prisoners,  and  moral 
reformation  of  criminals  likewise  .belong  especially  to  the  social 
aspects  of  the  question,  and  can  find  no  discussion  in  this  place. 

Regarding  the  remaining  proposition,  however,  that  which 
demands  that  the  State  shall  exercise  due  care  over  the  prisoner's 
health,  it  comprises  a  question  that  demands  consideration  in  a 
text-book  on  hygiene. 

There  is  now  a  general  concurrence  of  opinion  that  the 
State,  in  depriving  any  person  of  liberty,  has  no  right  to  subject 
the  individual  suffering  such  deprivation  to  any  danger  of  disease 
or  death.  In  other  words,  the  State  has  no  right  to  abbreviate 
the  life  of  the  convict  sentenced  to  prison.  This  proposition 
requires  that  the  State  see  to  it  that  the  prisoner  is  well  fed, 
well  clothed,  and  well  housed ;  that  he  shall  be  well  cared  for 
when  sick,  and  that  when  his  term  of  imprisonment  expires  he 
shall  be  set  at  liberty,  with  only  such  effect  upon  his  normal 
expectation  of  life  as  would  result  from  the  ordinary  wear  and 
tear  of  life  upon  his  health. 

It  must  be  confessed,  however,  that  the  State  is  very  far 
short  of  attaining  this  object.  The  mortality  of  convicts,  even 
in  the.  best-regulated  prisons,  where  especial  attention  is  paid  to 
the  sanitary  requirements  of  such  buildings,  is  three  times  as 


PRISON   HYGIENE.  281 

great  as  among  workmen  in  mines,  confessedly  one  of  the  most 
dangerous  occupations.  If  insurance  companies  desired  to 
insure  the  lives  of  prisoners,  the  companies  would  be  obliged,  in 
order  to  secure  themselves  against  loss,  to  make  the  premium 
equivalent  to  an  advance  in  age  of  twenty  years.  This  means 
that  a  free  person  has  as  long  an  expectation  of  life  at  40 
years  as  a  prisoner  has  at  20.  Attention  is  again  called  to 
the  fact  that  the  conditions  in  the  most  favorably  situated  and 
liberally  managed  prisons  only  are  here  considered.  What  the 
results  are  in  other  institutions,  less  favorably  constructed  and 
managed,  will  be  apparent  from  the  following  brief  statement : 
Mr.  George  W.  Cable  has  shown l  that  in  some  of  the  prisons 
in  the  Southern  States,  under  the  vicious  lease  system,  the 
mortality  is  eight  to  ten  times  greater  than  in  properly  con- 
structed and  managed  prisons  elsewhere.  In  Louisiana,  for 
example,  14  per  cent,  of  all  the  prisoners  died  in  1881 ;  and  in 
the  convict  wood-cutting  camps  of  the  State  of  Texas  one-half 
of  the  average  number  so  employed  during  1879  and  1880  died. 

The  mortality  of  prisoners  is  greatest  in  the  second,  third, 
and  fourth  years  of  their  confinement.  In  Millbank  Prison,  in 
England,  the  death-rate  per  1000  was  3.05  in  the  first  year, 
35.64  in  the  second,  52.26  in  the  third,  57.13  in  the  fourth,  and 
44.17  in  the  fifth  years  of  imprisonment. 

The  diseases  most  frequent  among  prisoners  are  pulmonary 
phthisis  and  diseases  of  inanition,  manifested  by  general  dropsy. 
Consumption  furnishes  from  40  'to  80  per  cent,  of  all  deaths. 
When  prisoners  are  attacked  by  acute  febrile  or  epidemic  diseases 
(small-pox,  cholera,  dysentery),  the  mortality  is  much  higher 
than  among  persons  in  a  state  of  liberty.  This  fatality  is  due 
to  an  aneemic  or  cachectic  condition,  which  has  been  called  "  the 
prison  cachexia," — a  depravement  of  constitution  which  yields 
readily  to  the  invasion  of  acute  diseases. 

Prisons  should  be  built  upon  a  healthy  site,  be  properly 
heated  and  ventilated,  have  an  abundant  water-supply,  and 

1  Century  Magazine,  February,  1884. 


282  TEXT-BOOK   OF   HYGIENE. 

be  supplied  with  facilities  for  a  prompt  and  thorough  removal 
of  sewage.  Baths  and  lavatories  should  he  conveniently  ar- 
ranged in  order  that  thorough  cleanliness  can  be  enforced. 

The  problem  of  feeding  prisoners  requires  careful  study. 
The  food  should  not  only  be  sufficient  in  quantity  and  of  good 
quality,  but  it  should  be  well  cooked,  and  the  bill  of  fare  varied 
often  in  order  to  avoid  creating  a  disgust  by  an  everlasting 
sameness.  Prisoners  often  suffer  from  nausea  and  other  digestive 
derangements,  brought  on  solely  by  the  monotonous  character 
of  the  daily  food. 

"  In  workshops  and  sleeping-rooms,  dormitories  or  cells,  the 
cubic  air-space  allowed  to  each  inmate  should  not  be  less  than 
17  cubic  metres,  with  proper  provision  for  ventilation.  The 
use  of  dark  or  damp  cells  as  places  o'f  confinement  is  a  relic  of 
the  barbarism  in  the  treatment  of  convicts  against  which  John 
Howard  raised  his  voice  so  effectively  in  the  last  century.  An 
abundance  of  sunlight  should  be  admitted  into  every  room  in 
which  a  human  being  is  confined. 

An  important  hygienic  measure  is  daily  exercise  in  the 
open  air.  It  should  be  regularly  enforced,  and  its  modes 
frequently  varied  in  order  that  it  may  not  degenerate  into  a 
mere  perfunctory  performance. 

Punishment  for  infractions  of  the  prison  discipline  should 
be  inflicted  without  manifestation  of  passion,  and  only  under  the 
immediate  direction  of  some  official  responsible  to  the  State. 
It  is  questionable  whether  physical  punishments,  such  as 
whipping,  tricing  up  by  the  thumbs  with  the  toes  just  touching 
the  floor,  bucking  and  gagging,  and  similar  barbarities  should 
be  permitted  under  any  condition.  The  permission  to  exercise 
such  power  is  extremely  liable  to  be  abused  by  officials.  The 
system  of  leasing  out  prisoners  to  private  parties,  which  prevails 
in  some  of  the  southern  United  States  is  vicious  in  the  extreme, 
because  it  places  the  convict  under  the  control  of  persons  not 
responsible  to  the  State,  and,  in  the  majority  of  instances,  morally 
unfitted  to  wield  the  power  of  inflicting  punishment. 


PRISON   HYGIENE.  283 

[The  following  works  on  prison  hygiene  and  prison  reform 
are  recommended  to  the  student : — 

A.  Baer,  Gefangniss-Hygiene,  in  von  Pettenkofer  und  Ziemssen's 
Handbuch  der  Hygiene,  II  Th.,  2  Abth. — Trans.  International  Peniten- 
tiary Congress,  London,  1882. — Trans.  National  Prison  Association, 
Baltimore,  1872. — G.  W.  Cable,  The  Convict-Lease  System  in  the  South- 
ern States,  Century  Magazine.  February  1884.] 


QUESTIONS   TO   CHAPTER  XII. 

PRISON  HYGIENE. 

How  does  the  mortality  of  those  who  are  in  prison  compare  with 
those  of  the  same  age  who  are  free?  What  philanthropists  called  early 
attention  to  the  abuses  of  prisons  and  prisoners  ?  What  fundamental 
propositions  now  practically  govern  prison  legislation  ?  Why  must  the 
State  exercise  due  care  over  the  prisoner's  health  ?  What  must  the  State 
do  to  attain  this  object  ?  Does  it  succeed  in  doing  it  ?  How  does  the 
excessive  mortality  compare  with  that  of  dangerous  occupations  ?  How 
does  the  expectation  of  life  compare  with  that  of  those  outside  of 
prison  ?  What  is  the  mortality  where  the  lease-system  obtains  ?  When 
is  the  mortality  among  prisoners  greatest?  What  diseases  are  most 
frequent  among  prisoners  ?  What  is  the  effect  of  acute  febrile  or 
epidemic  diseases  upon  prisoners  ?  To  what  is  this  due  ? 

What  principles  should  be  observed  in  prison  construction  ?  What 
points  should  be  particularly  observed  regarding  the  food  of  prisoners  ? 
How  much  air-space  should  be  allotted  to  each  prisoner,  whether  in 
workshops  or  cells  ?  What  precautions  should  be  taken  against  damp- 
ness and  absence  of  sunlight  ?  What  is  another  important  measure  that 
should  be  enforced  daily  ?  How  should  all  punishments  be  inflicted,  and 
what  ones  should  be  prohibited  ?  What  can  be  said  of  the  lease  system  ? 


(284) 


CHAPTER  XIII. 

EXERCISE  AND  TRAINING. 

THE  healthy  functions  of  the  bodily  organs  can  only  be 
maintained  by  more  or  less  constant  use.  A  muscle  or  other 
organ  that  is  unused  soon  wastes  away,  or  becomes  valueless  to 
its  .possessor.  On  the  other  hand,  trained  use  of  the  various 
organs  makes  them  more  effective  for  the  performance  of  their 
functions.  Thus,  by  practice,  the  eye  can  be  trained  to  sharper 
vision,  the  ear  to  distinguish  slight  shades  of  sound,  the  voice  to 
express  varying  emotions,  the  tactile  sense  to  accurately  appre- 
ciate the  most  minute  variations  of  surface  and  temperature,  and 
the  hand  to  greater  steadiness  or  the  performance  of  difficult 
and  complex  feats.  The  effectiveness  of  other  organs,  muscles, 
or  groups  of  muscles  can  also  be  increased  by  systematic  train- 
ing, as  is  seen  in  the  athlete  and  gymnast. 

PHYSIOLOGICAL   EFFECTS  OF  EXERCISE. 

When  a  muscle  contracts,  the  flow  of  blood  through  it  is 
increased.  Hence,  contraction  of  a  muscle,  which  consumes  or 
converts  stored-up  energy,  at  the  same  time  draws  upon  the  cir- 
culation for  a  new  supply  of  food-material  to  replace  that  con- 
sumed. The  activity  of  the  circulation  through  a  muscle  in 
action  results  in  increased  nutrition  and  growth  of  the  muscle. 

During  muscular  action  the  activity  of  the  respiratory 
process  is  increased.  A  larger  quantity  of  air  is  taken  into  the 
lungs,  more  oxygen  is  absorbed  by  the  blood,  and  an  increased 
elimination  of  carbon  dioxide  takes  place.  The  experiments  of 
Fettenkofer  and  Voit  show  that,  while  in  a  state  of  rest  the 
average  absorption  of  oxygen  in  twelve  hours  amounted  to  708.9 
grammes,  during  work  the  amount  reached  954.5  grammes. 

(285) 


286  TEXT-BOOK   OF   HYGIENE. 

For  the  same  period  the  elimination  of  carbonic  dioxide  was: 
during  rest,  911.5  grammes;  during  work,  1284.2  grammes. 

Upon  the  circulation  muscular  exercise  likewise  exerts  a 
manifest  influence.  The  action  of  the  heart  is  increased  both  in 
force  and  frequency,  the  arteries  dilate,  and  the  blood  is  sent 
coursing  through  the  system  more  rapidly  than  when  the  body 
is  at  rest. 

Cutaneous  transpiration  is  also  promoted  by  muscular  exer- 
cise. It  is  probable  that  in  this  way  some  of  the  effete  matters 
in  the  system  are  removed,  being  held  in  solution  and  carried 
through  the  skin  in  the  perspiration. 

PHYSICAL    TRAINING. 

There  can  be  no  question  that  systematic  training  of  the 
muscles  has  a  favorable  influence  upon  health  and  longevity. 
Persons  who  are  actively  engaged  in  physical  labor,  other  things 
being  equal,  are  healthier,  happier,  and  live  longer  than  those 
whose  occupation  makes  slight  demands  upon  their  muscular  sys- 
tem. In  default  of  an  active  occupation  the  latter  class  is  forced,  if 
good  health  is  desired,  to  adopt  some  form  of  exercise  which 
will  call  the  muscles  into  activity. 

The  principal  methods  of  physical  training  are  walking  or 
running,  rowing,  swimming,  and  the  various,  in-door  gymnastic 
exercises.  Rapid  walking  or  running  is  one  of  the  best  methods 
of  physical  exercise,  for,  not  only  are  the  muscles  of  the  legs  and 
thighs  developed,  but  the  capacity  of  the  chest  is  increased — one 
of  the  principal  objects  of  physical  training.  By  combining 
walking  with  some  form  of  in-door  gymnastics,  such  as  practice 
with  dumb-bells,  Indian  clubs,  rowing-machines,  or  pulley- 
weights,  nearly  all  the  good  effects  of  the  most  elaborate  system 
of  training  can  be  obtained. 

For  the  gymnastic  exercises  various  forms  of  useful  labor 
may  be  substituted  with  advantage,  such  as  wood-chopping  or 
sawing,  or  moderate  work  at  any  physical  labor. 

The  scheme  of  studies  in  our  public-school  system  should 


PHYSICAL   TRAINING.  287 

include  physical  training  for  both  sexes.  This  is  a  question  not 
merely  of  individual,  but  of  national  importance.  Weak  and 
unhealthy  children  are  not  likely  to  grow  up  into  strong  and 
healthy  men  and  women;  and  the  latter  are  necessary  for  the 
perpetuity  of  the  nation.  The  time  seems  to  have  arrived  when 
physical  education  should  no  longer  be  looked  upon  as  a  whim 
of  unpractical  enthusiasts  and  hobby-riders,  but  as  an  indispen- 
sable element  in  every  school  curriculum. 

There  is  a  tendency  among  instructors  in  physical  training 
to  make  their  systems  too  complicated,  or  dependent  upon  expen- 
sive or  cumbersome  apparatus.  This  is  to  be  deprecated.  Ail 
the  muscles  of  the  body  can  be  called  into  action  by  very  simple 
exercises,  easily  learned  and  readily  carried  out. 

An  important  preliminary,  to  all  methods  of  training  is  a 
thorough  physical  examination  of  the  pupil  by  a  competent 
physician,  in  order  to  determine  whether  certain  exercises  are 
allowable.  For  example,  in  all  organic  heart  affections  exer- 
cises of  a  violent  character  must  be  interdicted.  A  boy  or  man 
with  valvular  disease  of  the  heart  cannot  run,  row,  or  swim 
with  safety.  The  organ  is  easily  overtasked  in  this  condition 
and  liable  to  fail  in  its  function. 

One  of  the  simplest  and  best  methods  to  cause  the  pupil  to 
assume  a  correct  position  of  the  body,  and  to  acquire  ease  and 
grace  in  his  movements,  is  to  teach  him  the  "setting-up,"  as 
practiced  in  the  United  States  army.1 

In  walking,  a  free,  swinging  step  should  be  acquired,  with 
the  head  erect,  shoulders  thrown  back,  and  chest  well  to  the 
front,  the  whole  body  from  the  hips  upward  inclining  slightly 
forward.  The  clothing  should  be  loose  around  the  upper  part 
of  the  body,  in  order  not  to  interfere  with  the  freest  expansion 
of  the  chest,  and  to  give  the  lungs  and  heart  ample  room  for 
movement.  Even  in-door  gymnastic  exercises  alone,  when  prac- 
ticed under  intelligent  provision,  will  accomplish  very  favorable 
results,  as  shown  by  the  following  table: — 

1  Upton's  Infantry  Tactics.    School  of  the  Soldier,  Lesson  I. 


288 


TEXT-BOOK   OF   HYGIENE. 


TABLE  XXYII. 


Showing  Average  State  of  Development  on  Admission  to  Gymnasium  ;  Average  State 
of  Growth  and  Development  after  Six  Months'  Practicing  Two  Hours  a  Week, 
and  Average  Increase  During  that  Time.  (Bowdoin  College  Gymnasium,  under 
Dr.  D.  A.  Sargent.  Two  Hundred  Students  from  the  Classes  of  1873  to  1877, 
inclusive.  Average  Age,  18.3  Tears.}1 


On  Admission. 

After  Six 
Months' 
Practice. 

Average 
Increase. 

Height         

170.0  c 
60.7k 
87.5  c 
80.6 
25.0 
27.5 
38.7 
78.7 
48.7 
31.2 

in. 
B. 
11. 

170.6  c 
61.6k 
91.8  c 
82.4 
26.8 
29.0 
40.5 
84.4 
52.6 
33.0 

in. 
g- 
u. 

0.6  ci 
900.0  gi 
4.3  ci 
1.8 
1.8 
1.5 
1.8 
5.7 
3.9 
1.8 

n. 
us. 
n. 

Weight  

Chest  (inflated)        .          

Forearm   

Shoulders  ^idth)  

Thigh               ...          ...         .... 

Calf     .'  

The  table  on  the  following  page  shows  the  average  rate  of 
increase  in  development  in  a  two  years'  and  a  four  years'  class 
in  Amherst  College,  and  also  the  percentage  of  increase  in  one 
four  years'  class  from  entrance  to  graduation.  The  interest- 
ing fact  has  been  brought  out  by  Mr.  Delabarre  that  tobacco- 
smoking  has  a  decidedly  deleterious  effect  upon  the  rate  and 
percentage  of  physical  development  in  students.  In.  weight 
non-smokers  gained  24  per  cent,  over  smokers ;  in  height  37 
per  cent.,  and  in  chest-girth  42  per  cent. 

OVEREXERTION. . 

However  necessary  for  the  preservation  of  health  physical 
exercise  may  be,  overexertion  should  be  carefully  avoided. 
Overstrain  and  hypertrophy  of  the  heart  are  often  the  results  of 
excessive  exertion.  Dr.  Da  Costa  has  described  a  form  of  '•  irri- 
table "  and  weak  heart  occurring  especially  among  soldiers,  which 
he  has  clearly  traced  to  overexertion.  Severe  labor  and  violent 
athletic  exercises  have  been  followed  by  like  serious  results. 
Long-distance  pedestrianism  has  furnished,  within  recent  years, 
quite  a  number  of  individuals  who  were  broken  down  in  health 

1  Apparatus  used:   Weights,  4500  to  6750  grammes;   Dumb-bells,  1125  grammes;   Indian 
clubs,  1575  grammes  ;  Pulleys. 


OVEREXERTION. 


289 


TABLE  XXYIII. 

Showing  Physical  Gains  of  Students  in  Amherst  College  During  a  Part  and  During 
the  Whole  of  the  College  Course.  (Prof.  E.  Hitchcock,  Dr.  H.  H.  Seelye,  and 
Mr.  F.  A.  Delabarre.) 


GAIN  OF  Two 
YEARS'  CLASS. 

GAIN  OF  FOUR 
YEARS'  CLASS. 

Per  Cent, 
of 
Increase 
in  Class 
of  '91. 

Weight, 
H1fi*- 

Girth, 

2.72 

Breadth, 
2.93 

Strength, 
25.31 

Capacity, 
4.00 

Metric. 

English. 

Metric. 

English. 

Weight     

»2.6 
.11 
.3 
.4 
.8 
.4 
.14 
.5 
.10 
.14 
.9 
.10 
.15 
.19 
.13 
.4 
.3 
.9 
.11 
.2 
.2 
.13 
.11 
.14 
.6 
.6 
.4 
.3 
.1 
.2 
.1 
.2 
.11 
.7 
.2 
.2 
.3 
.2 
.2 
.2 
.2 
.1 
.19 
.14 
•  .73 
..30 
•  2.8 
b2.6 
bl.l 
».33 
•  .5 
•  .5 
«1.2 

d5.72 
.43 
.11 
.15 
.31 
.15 
.55 
.19 
.39 
.55 
.35 
.39 
.59 
.74 
.51 
.15 
.11 
.35 
.43 
.07 
.07 
.51 
.43 
.55 
.23 
.23 
.15 
.11 
.03 
.07 
.03 
.07 
.43 
.27 
.07 
.07 
.11 
.07 
.07 
.07 
.07 
.03 
.74 
.55 
4160.9 
d.66 
a61.7 

a  72.7 

dll.O 
dll.O 

.73.2 

5.40 
.16 
.11 
.9 
.5 
.12 
.18 
.7 
.14 
.41 
.34 
.41 
.36 
.24 
.25 
.6 
.7 
.13 
.10 
.8 
.9 
.13 
.17 
.16 
.6 
.5 
.5 
.6 
.2 
.3 
.3 
.4 
.19 
.13 
.9 
.11 
.4 
.4 
.10 
.6 
.5 
.4 
.24 
.20 
.82 
.64 
.28 
2.3 
1.2 
.37 
.7 
.5 
3.6 

11.8 
.63 
.43 
.35 
.19 
.47 
.7 
.27 
.55 
1.61 
1.33 
1.61 
1.41 
.94 
.98 
.23 
.27 
.51 
.39 
.31 
.35 
.51 
.66 
.62 
.23 
.19 
.19 
.23 
.07 
.11 
.11 
.15 
.74 
.51 
.35 
.43 
.15 
.15 
.39 
.23 
.19 
.15 
.94 
.78 
180.8 
1.41 
61.7 

81.5 
15.4 
11.0 
219.6 

8.9 

0.6    1 
0.7 
1.2 
3.3 
0.4 
1.3 
0.5    : 
2.5 
3.0 
1.0 
4.1 
2.4 
3.0 
3.1 
0.8 
1.1 
2.8 
2.3 
0.8 
0.8 
6.3 
6.4 
7.8 
3.5 
3.5 
3.3 
3.1 
0.0 
0.6 
0.6    k 
1.8 
3.6 
6.4 
3.4 
1.8 
1.1    = 
0.8 
1.5 
1.5 
1.1 
1.1 
1.3 
0.6 
26.9    -I 
27.8 
24.0 
38.0       . 
20.5 
26.0 
23.7 
15.6 
4.0 

Height      

Pubes    

Sitting  

Girth,  Head  

Neck      

Chest  repose  

Chest  full       

Belly  

Hips   

Right  thigh    

Left  thigh  

Right  knee  

Left  knee    

Right  calf   

Lett  calf  

Right  instep  

Left  instep  

Upper  right  arm  .   .   . 
U.  R.  A.  contracted  . 
Upper  left  arm    .  .  . 

Right  forearm  .  .  . 
Left  forearm  

Breadth  Head  

Shoulders    

Waist    

Hips   

Right-shoulder  elbow  .  . 
Lot  t-shnulder  elbow  .  .  . 

Left  elbow-tip  

Length,  Right  foot    .  .  . 
Left  foot  

Stretch  of  arms    

Horizontal  length  .... 

Lungs    

Back  

Chest  dip  

Chest  pull  up    .... 

Right  forearm  .... 
Left  forearm     .... 
Capacity  of  lungs   .... 

1  A  total  average  gain 
1       of  5.87  per  cent. 

a— Kilos,    b— Units. 


c — Litres,    d — Pounds,    e — Cubic  inches, 
and  Inches  and  Tenths. 


All  others,  Millimetres, 


by  the  excessive  strain  on  the  physical  organization  involved. 
Cardiac    strain   is    not   infrequent   among  this   class.     Spasm, 

in 


290  TEXT-BOOK    OF   HYGIENE. 

paralysis,  or  atrophy  of  muscles  sometimes  results,  when  these 
are  exhausted  by  uninterrupted  or  excessive  exercise.  This 
effect  is  shown  by  writers'  and  telegraphers'  cramp,  and  similar 
affections.  For  these  reasons  it  is  important  that  both  exercise 
for  health  and  actual  work  should  be  so  regulated  as  to  conduce 
to  the  individual's  benefit,  and  not  to  his  detriment. 

[On  the  subjects  embraced  in  this  chapter  the  following 
works  may  be  studied  with  advantage : — 

A.  Braynton  Ball,  :'  Physical  Exercise,"  in  Buck's  Hygiene  and 
Public  Health,  vol.  i. — Win.  Blaikie,  How  to  Get  Strong  and  How  to 
Stay  so. — A.  Maclaren,  Training  in  Theo^  and  Practice. — Hitchcock 
and  Seelye,  The  Ainherst  Anthropometric  Manual.] 


QUESTIONS  TO   CHAPTER  XIII. 

EXERCISE  AND  TRAINING. 

What  is  absolutely  necessary  for  the  maintenance  of  the  healthy 
functions  of  the  body  ?  What  is  the  effect  of  disuse  upon  any  organ  ? 
Of  training? 

What  occurs  when  a  muscle  contracts  ?  What  is  the  result  of  in- 
creased activity  of  circulation  in  a  muscle  ?  What  is  the  effect  of  mus- 
cular action  on  the  respiratory  process  ?  What  is  the  difference  as  to 
the  absorption  of  oxygen  in  a  state  of  rest  and.  during  work  ?  As  to  the 
elimination  of  carbon  dioxide  and  water  ?  What  is  the  effect  of  muscular 
action  upon  the  circulation  ?  Upon  the  cutaneous  transpiration  ? 

What  is  the  effect  of  systematic  training  upon  health  and  longevity  ? 
What  are  some  of  the  principal  and  best  methods  of  physical  training? 
What  is  one  of  its  most  important  objects?  How  may  the  various 
methods  be  combined  with  benefit? 

What  should  be  included  among  the  studies  and  work  of  all  public 
schools  ?  For  what  purposes  ?  What  is  the  tendency  among  instructors 
in  physical  training?  Is  this  necessan",  or  not?  Why? 

What  is  an  important  preliminary  to  all  methods  of  training? 
Why  ?  How  may  a  pupil  be  taught  to  assume  and  maintain  a  correct 
position  and  carriage  of  the  body  ? 

How  should  a  person  walk  ?  What  attention  should  be  given  to  the 
clothing  worn  during  exercise?  What  will  be  some  of  the  results  of 
systematic  physical  training  properly  pursued  ? 

What  are  some  of  the  results  of  overexertion  ?  Does  it  make  a 
difference  whether  the  exercise  is  too  long  uninterrupted  or  whether  it  is 
excessive  in  amount  and  character  ? 


(291) 


CHAPTER  XIV. 

BATHS  AND  BATHING. 

THE  most  important  sanitary  object  of  bathing  is  cleanli- 
ness. A  secondary  object  of  the  bath  is  to  stimulate  the  func- 
tions of  the  skin,  and  to  produce  a  general  feeling  of  exhilaration 
of  the  body.  Baths  are  used  of  various  temperatures.  A  cold 
bath  has  a  temperature  of  from  4°  to  24°  C.  (40°  to  75°  F.) ;  a 
tepid  bath  from  24°  to  30°  C.  (75°  to  85°  F.),  a  warm  bath  from 
30°  to  38°  C.  (85°  to  100°  F.),  and  a  hot  bath  from  38°  to  43° 
C.  (100°  to  110°  F.). 

Tepid,  warm,  or  hot  batJis  are  used  principally  as  cleansing 
agents  or  as  therapeutic  measures.  They  cause  dilatation  of 
the  cutaneous  capillaries,  diminish  blood-pressure,  and  reduce 
nervous  excitability.  The  hot  bath  is  also  a  method  for  restor- 
ing warmth  to  the  body  in  certain  cases  of  shock,  or  to  remove 
the  immediate  effects  of  injurious  exposure  to  low  temperature. 

The  so-called  Russian  and  Turkish  baths,  so  popular  in  the 
larger  cities  of  this  country,  are  modifications  of  vapor-  and  hot- 
air  baths,  or  rather  combinations  of  these  with  cold  baths.  The 
Turkish  bath  is  especially  to  be  recommended  for  its  depurative 
and  invigorating  effects. 

Cold  baths  are  used  not  merely  for  their  cleansing  effects, 
but  principally  for  their  stimulating  effects  upon  the  system. 
When  first  plunging  into  a  cold  bath  there  is  usually  a  moment- 
ary shock ;  the  respiration  is  gasping,  and  the  pulse  is  increased 
in  frequency.  These  symptoms  disappear  in  a  few  moments, 
however,  and  reaction  follows.  To  a  healthy  person  a  cold  bath 
is  a  delightful  general  stimulant,  removing  the  sense  of  fatigue 
after  physical  exertion  and  causing  an  extremely  refreshing 
sensation  throughout  the  body. 

(293) 


294  TEXT-BOOK   OF    HYGIENE. 

As  a  therapeutic  measure,  the  cold  bath  has  a  wide  field 
of  usefulness.  For  the  reduction  of  the  bodily  temperature  in 
fevers  and  inflammatory  diseases,  and  especially  in  heat-stroke, 
it  is  more  prompt  and  effective  than  any  other  agent  at  the  com- 
mand of  the  physician. 

Sea-Batliing. — The  most  stimulating  form  of  the  cold  bath 
is  doubtless  the  salt-water  bath  as  taken  at  the  sea-shore.  The 
revulsive  effect  of  the  impact  of  the  waves  and  breakers  upon 
the  skin  and  the  stimulation  due  to  the  saline  constituents  of 
the  sea-water  heighten  the  invigorating  effects  of  the  simple  cold 
bath.  The  beneficial  results  of  sea-bathing  are,  however,  not 
entirely  due  to  the  bath,  but  are  to  a  great  degree  dependent 
upon  the  bracing  air  of  the  sea-shore,  absence  of  the  care  and 
anxieties  of  business,  and  the  temporary  change  in  food  and 
habits  that  a  residence  at  the  sea-side  involves.  Nevertheless, 
salt-water  baths  are  more  stimulant  to  the  skin  than  those  of 
simple  water,  and  part  of  the  good  effects  of  sea-bathing  can 
often  be  obtained  from  a  salt-water  bath  taken  at  home.  The 
following  mixture  of  salts  dissolved  in  about  125  litres  of  water 
for  one  bath  makes  a  fairly  good  substitute  for  a  sea-bath : — 

Take  of  Chloride  of  sodium  (common  salt),     .        .        .4  kilogrammes. 
Sulphate  of  sodium  (Glauber's  salt),  .  .     2  " 

Chloride  of  calcium, £  kilogramme. 

Chloride  of  magnesium,       .        .        .    '     .        .     1^  kilogrammes. 

There  is  a  prevalent  popular  belief  that  it  is  extremely  dan- 
gerous to  enter  a  cold  bath  when  heated  or  perspiring.  The 
author  is  of  the  opinion  that  this  belief  is  erroneous.  The  stim- 
ulant and  bracing  effects  of  the  cold  bath  are  most  manifest  if  it 
be  taken  while  the  individual  is  very  warm  or  bathed  in  perspira- 
tion. Several  years  ago  the  author  made  a  series  of  observations 
upon  himself  to  determine  the  effects  of  the  cold  bath  when 
the  body  was  very  warm.  Every  afternoon  a  free  perspiration 
was  provoked  by  a  brisk  walk  of  about  2  kilometres  in  the  sun. 
As  soon  as  the  clothing  could  be  cast  off,  and  while  the  body 
was  still  freely  perspiring,  a  plunge  was  taken  into  a  fresh-water 
bath  of  about  15.5°  C.  (60°  R).  No  ill  results  followed;  on 


RULES   FOR   BATHING.  295 

the  contrary,  the  sensation  immediately  following  the  bath,  and 
for  six  or  eight  hours  afterward,  was  exceedingly  pleasant.  The 
health  remained  perfect,  and  the  weight  decidedly  increased 
during  the  two  months  the  practice  was  continued.  There  is 
probably  no  danger  to  a  healthy  person  in  this  practice,  but  it  is 
considered  advisable  to  immerse  the  head  first  ("  take  a  header  "), 
to  avoid  increasing  the  blood-pressure  in  the  brain  too  greatly, 
which  might  result  if  the  body  were  gradually  immersed  from 
the  feet  upward. 

RULES   FOR   BATHING. 

The  following  series  of  rules  have  been  issued  by  the 
English  Royal  Humane  Society,  and  are  all  worth  observing  by 
bathers :  "  Avoid  bathing  within  two  hours  after  a  meal.  Avoid 
bathing  when  exhausted  by  fatigue  or  from  any  other  cause. 
Avoid  bathing  when  the  body  is  cooling  after  perspiration. 
Avoid  bathing  altogether  in  the  open  air,  if,  after  having  been 
a  short  time  in  the  water,  there  is  a  sense  of  chilliness,  with 
numbness  of  the  hands  and  feet;  but  bathe  when  the  body  is 
warm,  provided  no  time  is  lost  in  getting  into  the  water.  Avoid 
chilling  the  body  by  sitting  or  standing  undressed  on  the  banks 
or  in  boats,  after  having  been  in  the  water.  Avoid  remaining 
too  long  in  the  water,  but  leave  the  water  immediately  if  there 
is  the  slightest  feeling  of  chilliness.  The  vigorous  and  strong 
may  bathe  early  in  the  morning  on  an  empty  stomach.  The 
young,  and  those  who  are  weak,  had  better  bathe  two  or  three 
hours  after  a  meal ;  the  best  time  for  such  is  from  two  to  three 
hours  after  breakfast.  Those  who  are  subject  to  giddiness  or 
faintness,  or  suffer  from  palpitation  or  other  sense  of  discomfort 
at  the  heart,  should  not  bathe  without  first  consulting  their 
medical  adviser." 

To  these  instructions  may  properly  be  added  that  a  warm 
or  hot  bath  should  be  avoided,  if  the  person  is  liable  to  ex- 
posure to  cold  within  a  few  hours  after  the  bath;  that  women 
should,  as  a  rule,  not  take  a  cold  bath  while  menstruating,  or 
during  the  last  two  months  of  pregnancy ;  and  that  persons 


296  TEXT-BOOK   OF   HYGIENE. 

suffering  from  organic  heart  disease  should  especially  avoid  surf- 
bathing. 

After  bathing  the  body  should  be  thoroughly  dried  with 
soft  towels,  otherwise  eczematous  eruptions  are  liable  to  follow 
in  the  parts  subject  to  friction  from  opposing  surfaces  of  the 
skin,  as  in  the  groins,  the  perinaeum  and  inner  surface  of  the 
thighs,  the  armpits,  or  the  under  surface  of  the  breasts  in 
women  in  whom  these  organs  are  large  and  pendant. 

Friction  of  the  skin  with  a  coarse  towel,  or  so-called 
"flesh-brush,"  is  a  popular  practice,  but  is  not  to  be  universally 
commended.  The  hypersemia  of  the  surface  thus  produced 
may  sometimes  induce  cutaneous  diseases  (erythema,  eczema, 
psoriasis)  in  those  predisposed. 

DANGERS   OF   COLD   BATHING. 

One  of  the  most  serious  dangers  of  cold  bathing,  but  which 
is  not  sufficiently  appreciated,  is  the  tendency  to  nausea  and 
vomiting  if  the  stomach  contains  much  food.  There  can  be  no 
doubt  that  many  of  the  cases  that  are  called  "  cramp,"  and  which 
frequently  result  in  drowning,  are  due  to  this  cause.1 

Cramps  of  the  various  muscles  sometimes  occur,  rendering 
the  bather  helpless,  and  if  in  deep  water  he  is  liable  to  drown 
before  assistance  can  reach  him. 

HOW   TO   RESTORE   THE   APPARENTLY   DROWNED. 

In  drowning  death  takes  place  by  asphyxia.  The  respira- 
tion is  arrested  by  the  submersion  of  the  head,  the  carbonized 
blood  gradually  poisons  the  system,  and  the  heart  ceases  to  beat. 
So  long  as  the  heart  will  react  to  its  appropriate  stimulus  the 
person  may  be  restored  to  life.  The  first  thing  to  do,  therefore, 
after  a  recently-drowned  person  is  taken  out  of  the  water,  is  to 
attempt  to  re-establish  the  arrested  respiration.  Several  methods 
are  in  use  for  this  purpose.  Sylvester's  is  one  of  the  simplest. 
It  is  as  follows : — 

1  So  far  as  the  author  is  aware,  Dr.  John  Morris,  of  Baltimore,  first  called  especial  atten- 
tion to  this  source  of  danger. 


HOW   TO    RESTORE   THE    APPARENTLY    DROWNED.  297 

The  body  being  placed  on  the  back  (either  on  a  flat  sur- 
face or,  better,  on  a  plane  inclined  a  little  from  the  feet  upward), 
a  firm  cushion  or  similar  support  (a  coat  rolled  up  will  answer) 
should  be  placed  under  the  shoulders,  the  head  being  kept  in  a 
line  with  the  trunk.  The  tongue  should  be  drawn  forward  to 
raise  the  epiglottis  and  uncover  the  windpipe.  The  arms  should 
be  grasped  just  above  the  elbows  and  drawn  upward  until  they 
nearly  meet  above  the  head,  and  then  at  once  lowered  and  re- 
placed at  the  side.  This  should  be  immediately  followed  by 
pressure  with  both  hands  upon  the  belly,  just  below  the  breast- 
bone. The  process  is  to  be  repeated  fifteen  to  eighteen  times  a 
minute. 

Several  years  since  the  Michigan  State  Board  of  Health 
published  a  method  which  is  comprehensive,  effective,  easily 
understood,  and  readily  carried  out.  This  method  has  also  been 
adopted  by  the  United  States  Life-Saving  Service.  The  follow- 
ing are  the  details  of  the  Michigan  method: — 

Rule  1. — Remove  all  the  obstructions  to  breathing.  In- 
stantly loosen  or  cut  apart  all  neck-  and  waist-  bands ;  turn  the 
patient  on  his  face,  with  the  head  down  hill ;  stand  astride  the 
hips  with  your  face  toward  his  head,  and,  locking  your  fingers 
together  under  his  belly,  raise  the  body  as  high  as  you  can  with- 
out lifting  the  forehead  off  the  ground,  and  give  the  body  a 
smart  jerk  to  remove  mucus  from  the  throat  and  water  from  the 
windpipe,  hold  the  body  suspended  long  enough  to  slowly  count 
one — two — three — four — -five,  repeating  the  jerk  more  gently 
two  or  three  times. 

Rule  2. — Place  the  patient  on  the  ground  face  downward, 
and,  maintaining  all  the  while  your  position  astride  the  body, 
grasp  the  points  of  the  shoulders  by  the  clothing ;  or,  if  the  body  is 
naked,  thrust  your  fingers  into  the  armpits,  clasping  your  thumbs 
over  the  points  of  the  shoulders,  and  raise  the  chest  as  high  as 
you  can  without  lifting  the  head  quite  off  the  ground,  and  hold 
it  long  enough  to  slowly  count  one — two — three.  Replace  him 
on  the  ground  with  his  forehead  on  his  flexed  arm,  the  neck 


298  TEXT-BOOK   OF   HYGIENE. 

straightened  out,  and  the  mouth  and  nose  free ;  place  your 
elhows  against  [the  inner  surface  of]  your  knees  and  your  hands 
upon  the  sides  of  his  chest  over  the  lower  ribs,  and  press  down- 
ward and  inward  witfy  increasing  force  long  enough  to  slowly 
count  one — two.  Then  suddenly  let  go,  grasp  the  shoulders  as 
before,  and  raise  the  chest ;  then  press  upon  the  ribs,  etc.  These 
alternate  movements  should  be  repeated  ten  or  fifteen  times  a 
minute  for  an  hour,  at  least,  unless  breathing  is  restored  sooner. 
Use  the  same  regularity  as  in  natural  breathing. 

Rule  3.  —  After  breathing  has  commenced  restore  the 
animal  heat.  Wrap  him  in  warm  blankets,  apply  bottles  of 
hot  water,  hot  bricks,  or  anything  to  restore  heat.  Warm  the 
head  nearly  as  fast  as  the  body  lest  convulsions  come  on.  Rub- 
bing the  body  with  warm  cloths  or  the  hands  and  slapping  the 
fleshy  parts  may  assist  to  restore  warmth  and  the  breathing  also. 

If  the  patient  can  surely  swallow,  give  hot  coffee,  tea,  milk, 
or  a  little  hot  sling.  Give  spirits  sparingly,  lest  they  produce 
depression. 

Place  the  patient  in  a  warm  bed,  and  give  him  plenty  of 
fresh  air.  Keep  him  quiet. 

Beware !  Avoid  delay.  A  moment  may  turn  the  scale  for 
life  or  death.  Dry  ground,  shelter,  warmth,  stimulants,  etc.,  at 
this  moment  are  nothing — artificial  breathing  is  everything — is 
the  one  remedy — all  others  are  secondary.  Do  not  stop  to  re- 
move wet  clothing.  Precious  time  is  wasted,  and  the  patient 
may  be  fatally  chilled  by  exposure  of  the  naked  body,  even  in 
summer.  Give  all  your  attention  and  efforts  to  restore  breath- 
ing by  forcing  air  into,  and  out  of,  the  lungs.  If  the  breathing 
lias  just  ceased,  a  smart  slap  on  the  face  or  a  vigorous  twist 
of  the  hair  will  sometimes  start  it  again,  and  may  be  tried  inci- 
dentally. Before  natural  breathing  is  fully  restored,  do  not  let 
the  patient  lie  on  his  back  unless  some  person  holds  the  tongue 
forward.  The  tongue  by  falling  back  may  close  the  windpipe 
and  cause  fatal  choking. 

Do  not  give  up  too  soon ;  you  are  working  for  life.     Any 


PUBLIC   BATHS.  299 

time  within  two  hours  you  may  be  oh  the  very  threshold  of 
success  without  there  being  any  sign  of  it.1 

PUBLIC    BATHS. 

In  all  large  cities  and  towns  provision  should  be  made  for 
free  public  baths,  conducted  under  official  supervision,  and  for 
the  especial  use  and  benefit  of  the  poorer  classes.  General 
cleanliness  is  not  merely  a  factor  in  the  preservation  of  the 
public  health,  but  there  is  good  reason  to  believe  that  the  cause 
of  good  order  and  decency  would  likewise  be  promoted  by 
furnishing  the  public  the  means  of  easily  and  cheaply  keeping 
clean.  Several  of  the  larger  cities  in  the  country  have  estab- 
lished public  baths  upon  a  limited  scale,  and  these  have  been 
very  popular  and  have  doubtless  been  of  great  benefit.  The 
author  has  shown2  that  about  five-sixths  of  the  inhabitants  of 
the  large  cities  in  the  United  States  have  no  facilities  for  bathing 
except  such  as  are  afforded  by  a  pail  of  water  and  sponge,  or 
in  summer  the  proximity  of  some  body  of  water  easily 
accessible.  The  most  economical  and  best  form  of  bath  for 
public  use  would  doubtless  be  the  needle  or  rain  bath  recom- 
mended by  the  author  in  the  paper  referred  to.  Mr.  W.  P. 
Gerhard  has  also  recently  strongly  advocated  this  form  of  bath. 

1  Report  of  Michigan  State  Board  of  Health,  1874,  pp.  91-99. 

3  Address  in  State  Medicine,  Journal  American  Medical  Association,  July  2, 1887. 


QUESTIONS   TO   CHAPTER   XIV. 

BATHS  AND  BATHING. 

What  is  the  most  important  object  of  bathing?  For  what  other 
purposes  may  baths  be  taken  ?  What  are  the  respective  temperatures 
of  so-called  cold,  tepid,  warm,  and  hot  baths  ?  What  are  the  physiologi- 
cal effects  of  the  last  three  ?  In  what  surgical  emergencies  may  the  hot 
bath  be  used  ?  For  what  are  cold  baths  used  ?  What  are  their  physio- 
logical effects  ?  How  may  the  cold  bath  be  used  therapeutic-ally  ? 

What  is  the  most  stimulating  form  of  cold  bath  ?  To  what  are  its 
beneficial  effects  due?  How  may  a  salt-water  bath  be  prepared  at  home ? 
Is  there  any  danger  to  the  healthy  in  cold  bathing  while  the  body  is  per- 
spiring freely  ?  What  precaution  should  be  taken  before  entering  a  cold 
bath  ?  What  rules  may  be  laid  down  for  bathing  in  the  open  air  ? 
When  is  the  best  time  for  bathing?  Who  should  not  bathe  without  pre- 
vious medical  advice?  When  should  hot  baths  not  be  taken?  What 
should  follow  all  baths  ? 

What  is  one  of  the  most  serious  dangers  of  cold  bathing  ?  How 
does  death  take  place  in  drowning  ?  What  is  the  indication  that  one 
apparently  drowned  may  still  be  restored  to  life  ?  Describe  Sylvester's 
method  of  artificial  respiration.  What  is  the  method  adopted  by  the 
United  States  Life-Saving  Service  ?  What  is  essential  after  breathing 
has  been  re-established  ?  How  should  spirits  be  given  ?  How  long 
should  efforts  to  restore  respiration  be  continued  ?  What  is  to  be 
avoided  ? 

What  are  some  of  the  arguments  in  favor  of  public  baths  in  large 
cities  ? 

What  is  the  most  economical  form  of  bath  for  public  use  ? 


(300) 


CHAPTER  XV. 

CLOTHING. 

THE  primary  object  of  clothing  is  the  protection  of  the 
body  against  the  injurious  influences  of  heat,  cold,  and  moist- 
ure. Secondarily,  the  moral  sense  of  civilized  communities 
demands  that  the  nude  human  body  shall  not  be  exposed  in 
public.  Hence,  there  are  moral  as  well  as  sanitary  reasons  for 
the  wearing  of  clothing ;  only  the  latter  can  be  considered  in 
this  place. 

Bodies  radiate  or  absorb  heat  accordingly  as  they  are  sur- 
rounded by  a  medium  having  a  lower  or  higher  temperature 
than  themselves.  In  order,  therefore,  to  avoid  chilling  of  the 
human  body,  if  exposed  to  a  temperature  below  37°  C.  (98°  F.), 
clothing  must  be  worn  to  prevent  or  retard  radiation  of  the 
body-heat.  Exposure  of  the  unprotected  body  to  a  low  tem- 
perature would  not  merely  cause  chilling  of  the  surface,  owing 
to  the  rapid  loss  of  heat,  but  would  incidentally  produce  con- 
gestion of  internal  organs  by  causing  constriction  of  the  super- 
ficial capillaries. 

Clothing  is  also  worn  as  a  protection  against  great  heat. 
The  head,  especially,  needs  protection  from  the  sun's  rays. 

CLOTHING    MATERIALS. 

The  materials  from  which  clothing  is  made  are,  princi- 
pally, cotton,  linen,  wool,  silk,  and  the  skins  of  animals.  Of 
these,  probably  the  most  universally  used  is  cotton.  It  is  cheap, 
durable,  does  not  shrink  when  wet,  absorbs  little  water,  and 
conducts  heat  readily.  It  is  therefore  especially  valuable  for 
summer  garments,  allowing  rapid  dissipation  of  the  body-heat 
and  evaporation  of  the  perspiration. 

Linen  conducts  heat  even  better  than  cotton,  and  is  for 

(301) 


302  TEXT-BOOK   OF   HYGIENE. 

this  reason  largely  used  for  summer  clothing.  Its  principal 
advantage  over  cotton  is  that  it  is  more  durable  and  less  harsh 
to  the  skin. 

Wool  absorbs  water  readily  and  is  a  bad  conductor  of  heat. 
It  is  therefore  valuable  as  a  winter  garment,  retarding  radiation 
from  the  body.  Woolen  undergarments  should  be  worn  at  all 
seasons,  in  order  to  prevent  too  rapid  changes  of  the  surface, 
and  so  invoking  diseases  depending  upon  chilling  of  the  body. 
Clothing  of  pure  wool  (flannels)  is  liable  to  irritate  the  skin 
of  some  persons.  A  mixture  of  wool  and  cotton,  known  as 
"  Saxony  wool,"  is  softer  and  less  irritating,  and  makes  a  serv- 
iceable substitute  for  pure  wool. 

Silk  is  often  used  for  undergarments.  It  is  light,  soft,  and 
a  bad  conductor  of  heat. 

The  skins  of  animals,  with  the  fur  on,  are  often  used  for 
outside  clothing.  They  furnish  great  protection  against  severe 
cold.  The  skin  is  impermeable  to  wind  and  rain,  while  the 
thick,  pilous  covering  of  fur  retards  to  a  very  great  degree  the 
radiation  of  heat.  In  British  America,  the  Northwestern 
States  and  Territories,  and  in  the  Arctic  regions,  the  use  of  skin 
clothing  is  necessary  for  comfort. 

As  a  protection  against  moisture  (rain  and  snow)  rubber 
cloth  is  used  for  overcoats,  etc.  While  it  serves  effectually  in 
keeping  out  the  rain,  it  prevents  evaporation  of  the  perspiration, 
increasing  the  liability  to  chill,  and  rendering  the  person  wear- 
ing it  very  uncomfortable,  except  in  cold  weather. 

Leather  is  used  almost  exclusively  in  the  manufacture  of 
foot-wear.  It  is  sometimes  used,  however,  for  other  articles  of 
clothing,  such  as  coats,  trowsers,  etc.  It  furnishes  most  effective 
protection  against  cold. 

The  color  of  the  clothing  is  of  great  importance.  Ex- 
posed to  the  sun,  white  wool  or  silk  absorb  very  little  more 
heat  than  linen  or  cotton,  but  the  same  material,  of  different 
colors,  when  exposed  to  the  sun's  rays,  exhibits  marked  differ- 
ences in  absorptive  capacity.  The  following  table  shows  the 


CLOTHING.  303 

results  of  some  experiments  of  Pettenkofer.     The  material  used 
was  cotton  shirting  of  the  colors  named : — 

White  absorbed 100  heat  units. 

Light  Sulphur  Yellow  absorbed         .        .  102  "  " 

Dark  Yellow  absorbed        ....  140  "  " 

Light  Green  absorbed         ....  155  "  " 

Turkey  Red  absorbed         .         .         .         .  165  "  " 

Dark  Gueen  absorbed          .         .         .         .  168  "  " 

Light  Blue  absorbed 198  "  " 

Black  absorbed 208  "  " 

When  protected  from  the  sun's  rays,  however,  the  material 
becomes  important  and  the  color  is  of  little  consequence.  Wool, 
being  a  bad  conductor  of  heat,  retards  radiation  from  the  body, 
and  is  hence  the  best  material  for  winter  clothing. 

Gases  and  vapors,  probably  also  disease-germs,  are  ab- 
sorbed by  clothing,  and  may  be  thus  conveyed  from  place  to 
place.  It  has  been  found  that  woolen  clothing  possesses  this 
power  of  absorption  to  a  much  greater  degree  than  linen  or 
cotton.  The  bad  odor  of  a  crowded  room  or  of  tobacco-smoke 
frequently  clings  to  woolen  garments  for  days,  although  they 
may  be  exposed  constantly  to  the  air  during  the  interval.  It 
would  be  advisable,  therefore,  that  physicians  attending  infec- 
tious diseases,  hospital  attendants  and  nurses,  should  wear  linen 
or  cotton  clothing  instead  of  woolen. 

Clothing  should  be  made  to  jit  properly.  It  should  not 
restrain  muscular  movements,  obstruct  the  circulation,  or  com- 
press organs.  Hence,  corsets,  belts,  and  garters  are  to  be  con- 
demned. It  is  a  fact  of  common  observation  that  moderately 
loose  clothing  is  warmer  than  close-fitting. 

Especial  attention  should  be  given  to  the  shape  and  fitting 
of  foot-wear.  Boots  and  shoes  are  usually  made  with  little 
regard  to  the  physiological  anatomy  of  the  foot,  and  as  a  result 
the  feet  of  most  Americans  are  deformed,  beauty  and  usefulness 
being  in  a  great  degree  sacrificed  to  the  Moloch  of  fashion.1 

1  See  a  practical  paper  by  Dr.  Benj.  Lee,  A  Shoe  That  Will  Not  Pinch,  in  Sanitarian  for 
June,  1884,  p.  493. 


304  TEXT-BOOK   OF   HYGIENE. 

Dyes  used  for  coloring  fabrics  are  sometimes  poisonous. 
The  author  lias  repeatedly  seen  troublesome  eruptions,  and  even 
ulcerations  of  the  legs,  from  wearing  stockings  dyed  with  aniline 
compounds. 

By  appropriate  treatment  clothing  can  be  made  non- 
inflammable.  Tungstate  and  phosphate  of  soda  are  used  to 
reduce  the  inflammability  of  fabrics.  The  addition  of  20  per 
cent,  of  tungstate  of  soda  and  3  per  cent,  of  phosphate  of  soda 
to  the  starch-sizing  used  for  stiffening  linen  is  effective.  The 
material  is  not  injured  by  it,  and  a  smooth  surface  and  polish 
can  be  obtained  under  the  hot  iron.  Prof.  Kedzie  has  recom- 
mended borax  for  the  same  purpose.  He  says :  "  The  simplest 
and  easiest  way  to  make  your  cotton  and  linen  fabrics  safe  from 
taking  fire  is  to  dissolve  a  heaped  teaspoonful  of  powdered  borax 
in  ^  pint  of  starch  solution.  It  does  not  injure  the  fabric, 
imparts  no  disagreeable  odor,  and  interferes  in  no  way  with  the 
subsequent  washing  of  the  goods.  It  does  not  prevent  the 
formation  of  a  smooth  and  polished  surface  in  the  process  of 
ironing.  Borax  can  be  found  in  every  village,  and  is  within 
the  reach  of  all.  It  is  a  cheap  salt,  and  its  use  for  this  purpose 
is  very  simple."1 

[The  following  works  may  also  be  studied  to  advantage: — 

Hammond,  Hygiene,  p.  579. — L.  Meyer,  Kleidung,  in  Realenc}rclo- 
psedie  d.  ges.  Heilk.,  Bd.  VII,  p.  446. — Yan  Harlingen,  Care  of  the  Person, 
in  Back's  Hygiene  and  Public  Health,  vol.  i.] 

1  Michigan  State  Board  of  Health,  p.  181.   1880. 


QUESTIONS   TO   CHAPTER  XV. 
CLOTHING. 

What  is  the  primary  object  of  clothing?  What  are  some  of  the 
secondary  objects?  What  are  the  probable  results  of  exposing  the 
unprotected  body  to  low  temperature  ?  What  part  of  the  body  needs 
special  protection  against  heat  ? 

What  are  the  principal  materials  from  which  clothing  is  made? 
Which  of  these  is  most  universally  used  ?  Why  ?  In  what  respect  is 
linen  superior  to  cotton?  Why  are  cotton  and  linen  not  suited  for  winter 
wear  or  cold  climates  ?  Why  are  silk  and  wool  better  for  such  uses  ? 
Why  should  wool  be  worn  next  the  skin?  What  gives  silk  its  value ? 
Why  are  furs  so  warm?  What  are  some  of  the  objections  to  the  use  of 
rubber  clothing  ?  For  what  is  leather  chiefly  used  ? 

Of  what  importance  is  the  color  of  the  clothing?  What  colors 
absorb  least  and  what  ones  most  heat  ?  If  protected  from  the  sun's  rays, 
which  is  the  most  important  in  the  absorption  of  heat,  material  or  color? 

What  deleterious  or  harmful  matters  are  absorbed  or  cling  to  cloth- 
ing? What  kinds  of  clothing  have  the  greatest  power  of  absorption.? 
What  precautions  should  those  attending  cases  of  infectious  diseases 
observe  ? 

Why  should  clothing  fit  properly?  What  parts  of  the  clothing 
should  not  be  too  tight  ?  What  disturbances  may  result  from  the  wear- 
ing of  clothing  that  is  too  tight  ?  How  may  improperly-dyed  clothing 
create  trouble  ?  How  may  clothing  be  rendered  practically  non-inflam- 
mable ? 


(305) 


CHAPTER  XVI. 

DISPOSAL  OF  THE  DEAD. 

WHEN  life  is  extinct  in  the  animal  body  decomposition 
begins.  This  may  be  either  putrefactive  or  non-putrefactive. 
The  difference  between  the  two  processes  has  been  explained  by 
Liebig.  In  putrefaction  of  organic  matters  only  the  elements 
of  water  take  part  in  the  formation  of  the  new  compounds  which 
result,  while  in  non-putrefactive  decomposition  or  decay  the 
oxygen  of  the  air  plays  an  important  part.  Putrefaction  can  go 
on  under  water,  while  decay  can  only  take  place  when  the 
supply  of  free  oxygen  is  abundant. 

The  prompt  removal  of  the  bodies  of  the  dead  from  the 
immediate  vicinity  of  the  living  is  a  matter  of  prime  sanitary 
importance.  If  death  results  from  a  contagious  or  an  infectious 
disease,  the  necessity  for  the  removal  of  the  corpse  is  evident. 
But,  even  where  there  is  no  danger  of  propagation  of  infectious 
disease,  the  products  of  putrefaction  and  decay  may  give  rise  to 
serious  derangements  of  health  if  allowed  to  pollute  the  air. 

The  chief  methods  of  disposal  of  the  dead  are  burial  in  the 
earth,  entombment  in  vaults,  and  cremation. 

INTERMENT. 

The  most  common  method  of  sepulture  is  burial  in  the 
earth.  The  corpse  is  usually  inclosed  in  a  case  (coffin)  of  wood 
or  metal,  and  buried  from  1  to  2  metres  deep.  Here  decom- 
position sets  in,  which  is  at  first  putrefactive  and  later  on  non- 
putrefactive.  In  the  course  of  several  years,  from  five  to  ten, 
the  entire  body,  with  the  exception  of  the  bones,  has  usually 
disappeared  and  become  converted  into  a  dry  mold. 

The  soil  of  a  burial-ground  should  be  dry  and  porous,  so 

(307) 


308  TEXT-BOOK   OF  HYGIENE. 

as  to  be  easily  permeated  by  the  air.  In  a  sandy  or  gravelly 
soil  the  decay  of  a  corpse  is  much  more  rapid  than  in  a  moist, 
clayey  soil.  In  the  latter  the  bodies  more  readily  undergo 
putrefaction,  or  become  converted  into  a  substance  termed  adi- 
pocere.  It  has  been  calculated  that  in  a  gravelly  soil  the  decay 
of  a  corpse  advances  as  much  in  one  year  as  it  would  in  sand  in 
one  and  two-thirds,  and  in  clay  in  two  to  two  and  one-third 
years.  The  decay  of  the  dead  bodies  is  principally  (if  not 
entirely)  dependent  upon  the  presence  of  living  vegetable  organ- 
isms. If  the  access  of  free  oxygen  is  prevented,  the  bacteria 
of  putrefaction  will  thrive  and  cause  putridity.  If,  however, 
the  soil  is  loose,  porous,  and  easily  permeable  by  the  air,  the 
bacteria  of  decay  will  be  present  and  produce  their  charac- 
teristic effects. 

The  barometric  pressure  seems  to  affect  the  decomposition 
of  dead  bodies.  For  example,  at  the  refuge  of  St.  Bernard,  in 
the  high  Alps,  the  bodies  of  those  dying  are  not  buried,  but 
exposed  to  the  air,  where  they  undergo  a  drying,  shrinking,  and 
mummification  instead  of  putrefaction  or  decay. 

Alternate  saturation  and  drying  of  the  soil  promotes  the 
rapidity  of  decay. 

Certain  occupations  are  said  to  produce  changes  in  the 
tissues  which  resist  decay.  Thus,  tanners  are  supposed  to  resist 
the  final  changes  of  the  tissues  longer  than  persons  of  other 
occupations.  Shakespeare  makes  the  grave-digger  in  Hamlet 
say:  "A  tanner  will  last  you  nine  years."  The  corpses  of  those 
poisoned  by  phosphorus,  arsenic,  sulphuric  acid,  or  corrosive 
sublimate  also  decay  more  slowly  than  those  of  cases  of  infectious 
diseases. 

All  the  tissues  may  be  converted  into  adipocere,  but  in  the 
large  majority  of  cases  only  the  fat  and  connective  tissue  undergo 
this  change. 

SUPPOSED    DANGERS   OF   BURIAL-GROUNDS. 

Popular  sanitary  literature  teems  with  supposed  instances 
of  the  injurious  influences  of  cemeteries  upon  the  health  of 


SUPPOSED   DANGERS   OF   BURIAL-GROUNDS.  309 

persons  living  in  their  vicinity.  An  unprejudiced  consideration 
of  the  subject  shows,  however,  that  there  is  no  trustworthy  evi- 
dence that  any  of  the  gases  exhaled  by  decaying  or  putrefying 
bodies  are  injurious  to  health.  The  air  of  closed  burial-vaults 
may  be  dangerous  from  the  large  proportion  of  carbon  dioxide 
contained  in  it,  but  the  other  gaseous  products  of  decomposition 
have  no  deleterious  effects.  The  dangers  to  health  from  the 
proximity  of  cemeteries  are  doubtless  very  much  exaggerated. 
Pettenkofer  and  Erismann  have  shown  that  a  single  large  privy- 
vault,  containing  about  17  cubic  metres  of  excrement,  gives  off 
nearly  as  large  an  amount  of  putrefactive  gases  in  the  course 
of  one  year  as  is  exhaled  by  a  burial-ground  containing  556 
decomposing  corpses  in  ten  years. 

Where  bodies  are  properly  buried,  and  the  ground  is  not 
overcharged  by  corpses,  it  is  not  probable  that  infectious  diseases 
are  propagated  from  interred  bodies.  There  are  no  facts  on 
record  which  show  that  such  an  event  has  occurred. 

The  dangers  of  pollution  of  water  by  cemeteries  have  also 
been  much  overestimated.  The  purifying  power  of  soil-strata, 
through  which  the  water  is  compelled  to  percolate  before  reach- 
ing the  well  after  becoming  charged  with  the  products  of  decom- 
position, is  in  most  cases  sufficient  to  remove  all  deleterious 
matters. 

Cemeteries  should  not  be  located  within  a  city,  but  must 
be  easily  accessible.  The  soil  should  be  dry  gravel  or  sand, 
with  a  low  ground-water  level.  The  graves  need  not  be  deeper 
than  1^  metres  to  the  top  of  the  coffin. 

ENTOMBMENT   IN   VAULTS. 

Burial-vaults  in  churches  or  in  the  open  air  should  be 
discountenanced.  The  gases  of  decomposition  are  given  off 
directly  to  the  air  without  the  modifying  power  of  the  soil,  and 
often  constitute  a  nuisance,  even  if  not  deleterious  to  health. 
Entombment  in  vaults  or  crypts  has  not  a  single  favorable 
circumstance  to  recommend  it. 


310  TEXT-BOOK   OF    HYGIENE. 

CREMATION. 

Within  recent  years  the  rapid  incineration  of  the  dead  in 
properly-constructed  furnaces  has  been  frequently  recommended. 
In  the  United  States  a  cremation  furnace  was  built  several  years 
ago  at  Washington,  Pa.,  by  the  late  Dr.  J.  C.  LeMoine.  Among 
the  remains  of  those  cremated  were  those  of  the  late  Dr.  Samuel 
D.  Gross,  the  distinguished  surgeon.  The  practice  has  not 
gained  very  many  adherents,  however,  although  cremation 
societies  have  been  organized  and  furnaces  built  in  several  of 
the  cities  throughout  the  country.  Aside  from  the  objections 
urged  by  the  more  conservative  classes,  who  desire  to  adhere  to 
the  time-honored  custom  of  interment,  serious  legal  objections 
have  been  brought  forward.  In  cases  where  poisoning  is 
suspected  some  time  after  death,  the  cremation  furnace  would 
have  destroyed  every  evidence  of  crime,  and  conviction  of  a 
criminal  poisoner  could  not  be  obtained. 

The  real  advantages  of  cremation,  such  as  rapid  destruction 
of  a  corpse,  economy  of  space  in  keeping  the  remains,  and 
avoidance  of  pollution  of  the  soil  by  decaying  bodies,  and  pos- 
sible pollution  of  air  and  water,  are  more  than  counterbalanced 
by  the  expense  and  the  medico-legal  objection  mentioned.  From 
a  sanitary  point  of  view,  cremation  is  not  necessary  in  this 
country.  A  proper  regulation  of  cemeteries  will  prevent  any 
possible  dangers  to  the  living  from  pollution  of  the  air,  soil,  or 
water  by  the  decaying  remains  of  human  beings. 

INTERMENT    ON    THE   BATTLE-FIELD. 

After  battles,  the  disposal  of  the  bodies  of  the  slain  is 
often  a  serious  problem.  Naegeli  proposes  the  following  method 
of  interment :  After  selecting  the  place  of  burial,  the  sod  and 
layer  of  humus  are  removed  from  a  sufficiently  large  surface  and 
thrown  to  one  side.  The  corpses  are  then  laid  upon  the  denuded 
place,  and  the  layers  of  corpses  separated  by  sand,  gravel,  or 
fine  brush-wood.  A  trench  is  then  dug  around  the  pile  of  dead 
and  the  soil  gained  is  thrown  over  the  corpses  until  they  are 


INTERMENT    ON    THE   BATTLE-FIELD.  311 

covered  to  a  depth  of  1  metre,  when  the  humus  and  sod  are 
placed  over  the  whole.  This  furnishes  a  dry  grave  in  which 
decay  rapidly  takes  the  place  of  putrefaction,  and  the  corpses 
soon  molder  away.  The  same  procedure  may  be  followed  in 
cases  of  epidemics  where  the  number  of  deaths  is  too  great  to 
properly  bury  them  in  single  graves. 


QUESTIONS   TO   CHAPTER  XVI. 
DISPOSAL  OF  THE  DEAD. 

What  is  the  difference  between  putrefactive  and  non-putrefactive 
decomposition  ?  Why  must  the  dead  be  removed  from  the  living?  What 
are  the  chief  methods  of  disposal  of  the  dead?  Which  is  the  most 
common  ? 

Why  should  the  soil  of  burial-grounds  be  dry  and  porous  ?  Upon 
•what  is  the  decay  of,  dead  bodies  dependent  ?  What  is  the  usual  length 
of  time  required  for  the  decay  of  a  human  body?  What  may  affect  the 
length  of  this  period  ?  What  changes  other  than  decay  may  the  body 
undergo  ? 

Is  there  any  evidence  that  the  air  from  cemeteries  is  dangerous  to 
health  ?  In  what  way  may  the  air  from  a  closed  burial-vault  be  detri- 
mental? Is  it  probable  that  infectious  disease-germs  are  disseminated 
from  dead  bodies  ?  Is  the  pollution  of  water  by  cemeteries  probable  ? 
What  agents  serve  to  prevent  this  ?  Where  should  cemeteries  be  located, 
however  ?  Why  should  entombment  in  vaults  be  discountenanced  ? 

What  are  the  advantages  of  cremation?  What  are  the  objections 
to  it  ?  Is  it  necessary,  from  a  sanitary  point  of  view,  in  this  country  ? 

How  may  the  bodies  of  the  dead  be  interred  after  battles,  or  in  case 
of  very  fatal  epidemics  ?  What  are  the  advantages  of  this  method  ? 


(312) 


CHAPTER  XVII. 

THE  GERM  THEORY  OF  DISEASE. 

THE  ruling  doctrine  in  the  pathology  of  the  present  day  is 
the  germ  theory  of  disease.  Based  upon  the  doctrine  of  omne 
minim  ex  vivo,  and  supported  by  strong  experimental  and  clinical 
evidence,  it  is  accepted  by  the  great  majority  of  physicians.  Its 
advocates  claim  that  the  large  class  of  diseases  known  as  con- 
tagious or  infectious  are  all  due  to  the  presence  in  the  blood  or 
tissues  of  minute  organisms,  either  animal  or  vegetable.  Many 
other  diseases,  not  at  present  included  in  the  above  class  by 
general  pathologists,  are  also  believed,  by  the  adherents  of  the 
germ  theory,  to  be  caused  in  the  same  way.  The  following  con- 
stitutes a  brief  review  of  the  most  prominent  facts  in  the  history 
of  the  doctrine  : — 

The  doctrine  of  the  vital  nature  of  the  contagium  of  dis- 
ease— the  contagium  animatum  of  the  older  writers — was  held 
in  a  vague  way  by  many  of  the  physicians  of  the  past,  but  it  was 
not  until  the  latter  part  of  the  last  century  that  the  theory  took 
definite  shape.  In  the  works  of  Hufeland,  Kircher,  and  Linne 
the  idea  is  expressed  with  more  or  less  directness  that  the  propa- 
gation of  infectious  diseases  depends  upon  the  implantation  of 
minute  independent  organisms  into  or  upon  the  affected  indi- 
vidual. This  hypothesis  was,  however,  first  clearly  enunciated 
and  defended  with  great  force  by  Henle  in  1840.  Three  years 
earlier,  Cagniard  de  la  Tour  and  Schwann  had  established  a 
rational  basis  for  the  theory  by  their  observations  upon  the  yeast- 
plant  and  its  relation  to  fermentation.'  In  1835  Bassi  had  dis- 
covered in  the  bodies  of  silk-worms  affected  by  muscardme,  a 
disease  of  these  insects  which  proved  very  destructive,  a  para- 
site which  was  soon  shown  to  be  the  cause  of  the  disease. 
Within  the  next  few  years,  Tulasne,  DeBary,  and  Kuehn 

(313) 


314  TEXT-BOOK   OF    HYGIENE. 

proved  that  certain  fungi  were  the  causes  of  the  potato-rot  and 
other  diseases  of  plants.  Schoenlein,  Malmsten,  and  Gruby, 
between  1840  and  1845,  demonstrated  that  those  skin  diseases 
of  man  classed  as  the  tinece  were  due  entirely  to  the  action  of 
vegetable  parasitic  organisms. 

Up  to  this  time  the  germ  theory,  as  now  accepted,  had 
received  no  support  from  experiments.  All  the  diseases  claimed 
as  parasitic  were  purely  local ;  so  far  as  the  parasitic  nature  of 
the  general  diseases  was  concerned,  all  was  hypothetical.  In 
1849,  Guerin  Meneville  discovered  a  corpuscular  organism  in 
the  blood  of  silk-worms  affected  by  the  pebrine,  which  was  later 
proven  by  Pasteur  to  be  the  true  cause  of  this  destructive  dis- 
ease. Pollender,  in  1855,  and  Brauell,  in  1857,  found  numer- 
ous minute  rod-like  organisms  (bacteria)  in  the  blood  of  animals 
dead  from  splenic  fever.  In  1863  Davaine  investigated  the 
subject  more  fully,  and  showed  beyond  doubt  that  the  little 
organisms  discovered  by  Pollender  were  the  true  cause  of  splenic 
fever,  or  anthrax.  The  more  recent  researches  of  Robert  Koch 
upon  the  history  of  these  bacteria  or  bacilli  of  splenic  fever 
have  removed  all  doubt  of  their  etiological  significance. 

In  1883  the  last-named  observer  startled  the  medical  world 
by  the  assertion  that  consumption  or  tuberculosis  was  a  disease 
of  microbic  origin,  and  dependent  upon  the  presence,  in  the 
affected  tissues,  of  an  organism  whicli  he  named  bacillus  tuber- 
culosis. Much  controversy  arose  upon  this  point,  but  Koch 
fortified  his  position  so  strongly  with  proofs,  both  experimental 
and  clinical,  that  it  may  now  be  regarded  as  fully  demonstrated. 
Koch  has  likewise  shown  (1885)  that  Asiatic  cholera  is  due  to 
a  bacterial  organism,  termed  by  him  the  "  comma  bacillus," 
from  its  shape.  It  is  generally  regarded  by  bacteriologists,  how- 
ever, to  belong  to  the  class  of  organisms  known  as  spirilla,  and 
not  to  the  bacilli.  Eberth  discovered  the  bacillus  which  is  now 
generally  accepted  as  the  cause  of  typhoid  in  1880 ;  Fehleisen, 
the  micrococcus  of  erysipelas  in  1883;  Obermeier,  the  spirillum 
of  relapsing  fever  in  1868;  Schutz  and  Lofner  discovered  the 


THE   GERM   THEORY   OF   DISEASE.  315 

bacillus  of  glanders  in  1882 ;  Neisser  announced  the  discovery 
of  the  micrococcus  of  gonorrhoea  in  1879.  The  bacillus  of 
leprosy  was  discovered  by  Hansen  in  1879.  The  micro-organ- 
isms of  malaria  (oscillaria  malariae),  which  are  believed  to  be 
animal  organisms,  were  discovered  by  Laveran  in  1881.  This 
organism  is  different  from  the  bacillus  malarice  of  Klebs  and 
Tornnmsi-Crudeli,  which  possesses  no  pathological  significance. 
Pneumonia  may  also  be  regarded  as  a  microbic  disease,  since 
Sternberg,  Weichselbaum,  and  Frankel  have  shown  the  constant 
presence  of  the  micrococcus  Pasteurii  in  the  sputa  in  that 
disease.  In  1887  Nicolaier  and  Rosenbach  proved  that  tetanus 
is  due  to  a  bacillus. 

The  careful  observations  and  researches  of  the  investigators 
mentioned,  as  well  as  of  many  others  who  have  worked  earn- 
estly in  this  field,  have  established  the  germ  theory  of  disease 
upon  a  secure  foundation.  For  the  diseases  mentioned  the 
parasitic  origin  may  be  accepted  as  fully  proven.  For  a  number 
of  others,  among  which  may  be  mentioned  small-pox,  yellow  fever, 
diphtheria,  scarlet  fever,  typhus  fever,  measles,  hydrophobia,  etc., 
the  etiological  connection  between  the  disease  and  certain  hypo- 
thetical organisms  not  yet  discovered  appears  probable. 

In  connection  with  the  germ  theory  there  has  arisen  of  late 
a  very  important  question  in  its  bearing  upon  preventive  medi- 
cine. This  is  the  value  of  the  so-called  protective  inoculations 
against  infectious  diseases.  The  protective  influence  of  vacci- 
nation against  small-pox  is  firmly  established  by  indubitable 
evidence.  Within  the  last  three  or  four  years  a  procedure  in- 
troduced by  Pasteur  to  protect  animals  against  certain  fatal  in- 
fectious diseases,  such  as  splenic  fever,  fowl-cholera,  and  rabies, 
has  claimed  much  attention.  Pasteur's  observations  were  first 
made  upon  the  disease  termed  chicken-cholera.  He  found  that- 
the  blood  of  the  dead  fowls,  or  of  those  attacked  by  the  disease, 
swarmed  with  bacteria.  Inoculation  of  healthy  fowls  with  this 
diseased  blood,  or  with  the  bacteria  alone,  carefully  freed  from 
all  animal  fluids,  produced  the  same  disease.  The  bacteria 
were  therefore  assumed  to  be  the  cause  of  the  disease.  The 


316  TEXT-BOOK   OF   HYGIENE. 

investigator  then  took  a  quantity  of  these  bacteria  and  "  culti- 
vated "  them  through  a  number  of  generations,  using  sterilized 
chicken-broth  as  a  culture  medium.  Fowls  inoculated  with  the 
result  of  the  last  cultivation  were  still  attacked  by  the  same 
symptoms,  but  in  a  very  mild  degree,  and  almost  uniformly 
recovered  from  the  disease.  On  subsequent  inoculation  with 
infected  blood  no  effect  was  produced  upon  the  "  vaccinated  " 
fowls,  while  the  same  blood  introduced  into  fowls  not  "  pro- 
tected "  by  the  previous  inoculation  produced  its  customary 
fatal  effect.  Pasteur  and  others  repeated  these  experiments 
with  the  organisms  found  in  the  blood  in  splenic  fever  and 
obtained  similar  results.  Inoculations  made  with  cultivations 
from  the  spinal  cord  of  animals  suffering  from  rabies  have  also 
been  claimed  as  protective  against  this  disease  and  hydrophobia. 
These  protective  inoculations  have  been  made  upon  large  num- 
bers of  sheep  and  cattle  within  the  past  three  years,  and  with 
very  remarkable  success.  Recently,  however,  it  has  been  shown 
that  the  protection  afforded  by  the  inoculation  is  a  very  tem- 
porary one,  and  that  after  a  variable  but  brief  interval  the  pro- 
tected animals  are  again  liable  to  be  fatally  attacked  by  the 
disease.  The  opinion  seems  to  be  justified  that  cultivation  pro- 
duces only  a  temporary  degeneration  of  the  bacteria,  which 
rapidly  disappears  when  the  organisms  are  again  brought  in 
relation  with  their  proper  nutritive  fluid.  The  "  protective  in- 
oculations "  produce  a  mild  attack  of  the  disease,  \vhich  is  for  a 
time  a  bar  against  a  second  attack;  but  the  effect  soon  wears  off, 
leaving  the  animal  in  its  pristine  condition  of  receptivity  toward 
the  infective  material. 

[The  following  works  on  this  subject  are  recommended  to 
the  student : — 

Sternberg  and  Magnin,  The  Bacteria;  second  edition. — Fluegge, 
Fermente  und  Mikroparasiten,  in  von  Pettenkoffer  und  Ziemssen's 
Handbuch  d.  Hygiene.] 


QUESTIONS   TO    CHAPTER  XVII. 
THE  GERM  THEORY  OP  DISEASE. 

What  is  meant  by  the  germ  theory  of  disease?  When  did  this  doc- 
trine first  take  definite  shape  ?  When  was  it  first  clearly  enunciated,  and 
by  whom?  What  basis  was  there  then  for  it?  What  subsequent  evi- 
dence soon  developed?  What  was  the  first  evidence  of  the  parasitic 
nature  of  general  diseases  ?  Who  discovered  and  who  first  demonstrated 
the  true  cause  of  anthrax  ?  Who  proved  tuberculosis  to  be  of  microbic 
origin  ?  When  ?  What  other  diseases  are  now  known  to  be  caused  by 
specific  micro-organisms  ?  What  others  are  probably  due  to  a  like 
cause  ? 

What  effect  has  the  establishing  of  the  germ  theory  upon  preventive 
medicine  ?  What  is  meant  by  protective  inoculation  ?  What  evidence 
is  there  that  this  is  possible  How  do  disease  germs  produce  their  char- 
acteristic effects  upon  the  system  ?  How  may  the  inoculating  material 
be  prepared  ?  What  are  some  of  the  theories  regarding  the  method  by 
which  susceptible  animals  or  persons  are  rendered  immune?  Does  the 
protection  by  inoculation  seem  to  be  permanent  ? 


(317) 


CHAPTER  XVIIL 

CONTAGION  AND  INFECTION. 

THE  adjectives  "contagious"  and  "infectious"  are  used  to 
designate  certain  diseases  which  are  propagated  by  immediate 
contact,  or  through  the  intervention  of  some  other  medium,  from 
the  sick  to  the  healthy.  The  matters  in  which  reside  the  mor- 
bific power  are  now  believed  by  many  to  be  vegetable  organisms, 
but  not  a  few  pathologists  hold  to  the  view  that  the  real  con- 
tagia,  or  disease-bearing  agents,  are  modified  animal  cells  or 
abnormal  fluids. 

The  differentiation  between  contagion  and  infection  is  not 
easy.  Many  of  the  diseases  commonly  called  contagious  are 
also  infectious ;  that  is,  they  are  propagated  not  merely  by  direct 
contact,  but  also  by  air,  water,  or  food  which  may  have  become 
infected  with  the  morbific  agents.  Syphilis,  for  example,  may 
be  regarded  as  simply  a  contagious  disease ;  at  the  present  day, 
at  least,  we  cannot  conceive  syphilis  to  be  propagated  by  breath- 
ing infected  air  or  drinking  water  contaminated  with  the  poison 
of  syphilis.  Cholera,  typhoid,  and  yellow  fevers,  on  the  other 
hand,  are  examples  of  infectious  diseases,  neither  of  them  being 
directly  contagious,  but  conveyed  from  sick  to  well  through  the 
medium  of  contaminated  air,  water,  or  food.  Between  these 
two  stand  small-pox  and  typhus  fever  (and  perhaps  the  other 
exanthemata),  which  are  not  merely  contagious,  but  infectious 
also. 

There  is  still  a  third  class  of  acute  diseases  not  properly 
included  in  either  of  the  classes  mentioned.  This  is  the  class  of 
miasmatic  diseases,  of  which  malarial  fevers  are  the  type.  Ac- 
cording to  recent  observations,  pneumonia  and  epidemic  influenza 
ought,  perhaps,  to  come  in  this  class. 

The  contagious  and  infectious  diseases  are  of  particular 

(319) 


320  TEXT-BOOK   OF   HYGIENE. 

interest  to  sanitarians,  because  it  is  believed  that  by  judicious 
carrying  out  of  sanitary  measures  they  can  be  prevented.  Hence 
they  are  sometimes  termed  preventable  diseases.  Another  pecu- 
liarity of  the  infectious  diseases  is  that  they  usually  occur  in 
groups  of  cases.  Thus,  small-pox,  measles,  scarlet  fever,  typhus 
fever,  diphtheria,  and  others  of  the  class  do  not  occur  sporadi- 
cally, as  it  is  termed ;  that  is  to  say,  it  rarely  happens  that  only 
one  case  of  small-pox  is  observed  in  a  locality,  unless  active 
measures  are  at  once  taken  to  stamp  it  out.  Usually  a  number 
of  cases  occur  successively,  and  in  most  instances  the  succeeding 
cases  can  be  traced  ultimately  to  the  first  case. 

Contagious  and  infectious  diseases  frequently  appear  as 
epidemics.  Authorities  differ  as  to  the  proper  definition  of  an 
epidemic;  that  is,  given  the  population  of  a  place,  how  many 
cases  of  an  infectious  or  contagious  disease  are  necessary  before 
the  disease  can  be  considered  epidemic  at  such  place.  The 
following  formula  was  given  by  the  New  Orleans  Medical  and 
Surgical  Association  in  response  to  the  query,  "Under  what  cir- 
cumstances is  it  proper  to  declare  such  diseases  (diphtheria, 
scarlet  fever,  measles,  small-pox,  yellow  fever,  etc.)  epidemic  in 
a  place]"  The  answer  given  is  that  the  disease  should  be 
declared  epidemic  when  the  number  of  cases  should  reach  these 
proportions1 : — 

For  a  population  of  100      ...  5  per  cent. 

"  "  "  500      ...  4  "  " 

"  "  "  2,000  to      5,000    .  221  «  thousand. 

"  "  "  6,000  to    10,000    .  16  "           " 

"  "  "  20,000  to    50,000    .  8  "  ten  thousand. 

"  "  "  50,000  to  100,000    .  4  "  "           " 

"  "  "  200,000  1  "  "          " 

A  disease  is  said  to  be  pandemic  when  it  spreads  rapidly 
over  a  great  extent  of  country,  and  endemic  when  it  is  constantly 
present  in  a  place.  Diseases  which  may  be  prevalent  in  certain 
localities,  i.e.,  endemic,  not  infrequently  spread  over  larger  areas 

»  Public  Health,  vol.  vi,  pp.  416,  417. 


CONTAGION    AND    INFECTION.  321 

of  country, — overflow  their  borders,  as  it  were, — and  become  epi- 
demic or  pandemic.  Thus  cholera,  which  is  endemic  in  certain 
districts  of  India,  frequently  spreads  over  adjacent  territory,  and 
at  times  the  epidemic  wave,  as  it  has  been  called,  rolls  over 
nearly  the  whole  world.  Plague,  malarial  and  yellow  fevers 
make  similar  epidemic  excursions  into  other  countries,  or  sec- 
tions of  country,  at  a  distance  from  the  places  where  they  are 
endemic. 

Contagious  and  infectious  diseases  possess  another  peculi- 
arity in  that  a  certain  time  is  required  after  the  introduction  of 
the  poison  into  the  system  before  the  disease  manifests  itself  by 
its  typical  symptoms.  This  is  called  the  "stage  of  incubation," 
and  varies  for  different  diseases.  The  following  table  shows  the 
stage  of  incubation  of  a  number  of  such  diseases : — 

TABLE  XXIX. 

INCUBATION   OF   INFECTIOUS   DISEASES. 

Measles, 10  days. 

Small-pox, 12  " 

Mumps, 18  " 

Diphtheria, 3  " 

Scarlet  fever,    .......  3  " 

Whooping-cough,     .         .                  .         .         .  14  " 

Typhoid  fever, 14  " 

Typhus  fever, 1  to  2  " 

Chicken-pox, 4  " 

Erysipelas, 4  " 

The  period  during  which  the  infectiveness  of  the  patient 
lasts  also  varies.  In  some  cases  it  probably  depends  upon  the 
measures  taken  to  prevent  the  spread  of  the  disease,  e.g.,  disin- 
fection of  the  patient  and  his  surroundings. 

The  London  Clinical  Society  has  very  recently  made  public 
a  report  by  one  of  its  committees,  which  has  for  several  years 
carefully  studied  the  questions  of  incubation  and  the  duration 
of  infection.  The  conclusions  reached  do  not  differ  essentially 
from  those  in  the  above  table,  but  as  they  are  given  somewhat 
more  in  detail  they  are  here  appended : — 

21 


322  TEXT-BOOK   OF   HYGIENE. 

Diphtheria,  two  to  seven  days ;  oftenest  two. 

Typhoid  fever,  eight  to  fourteen  days;  sometimes  twenty- 
three. 

Influenza,  one  to  four  days ;  oftenest  three  to  four. 

Measles,  seven  to  eighteen  days ;  oftenest  fourteen. 

Mumps,  two  to  three  weeks ;  oftenest  three  weeks. 

Rubeola,  two  to  three  weeks. 

Scarlet  fever,  one  to  seven  days ;  oftenest  two  to  four. 

Small-pox,  nine  to  fifteen  days ;  oftenest  twelve. 

Further  investigations  were  made  with  regard  to  the  time 
and  duration  of  the  infective  period. 

Diphtheria  was  found  to  be  infective  during  the  period  of 
incubation,  attack,  and  convalescence. 

Mumps  and  rubeola  are  also  infective  for  three  or  four  days 
before  the  onset  of  the  parotiditis  and  appearance  of  the  rash. 

The  contagiousness  of  measles  speedily  disappears,  and 
does  not  continue  in  disinfected  persons  for  over  three  weeks. 

Typhoid  fever  is  infectious  from  the  time  of  onset  until  two 
weeks  after  the  fever  has  gone  and  convalescence  set  in. 

As  is  well  known,  the  contagiousness  of  scarlet  fever  varies 
greatly,  but  is  generally  continued  a  very  long  time — certainly 
until  desquamation  ceases,  and  sometimes  as  long  as  eight 
weeks. 


QUESTIONS  TO  CHAPTER   XVIII. 

CONTAGION  AND  INFECTION. 

What  is  the  difference  between  a  contagious  and  an  infectious  dis- 
ease ?  Give  examples  of  each.  What  diseases  do  not  belong  to  either 
of  these  classes  ?  What  other  names  might  be  given  to  contagious  and 
infectious  diseases  ?  How  do  they  usually  occur  ?  What  are  their  ex- 
citing causes  ?  How  may  they  be  prevented  ? 

What  is  an  epidemic  ?  When  may  a  disease  be  declared  epidemic 
in  a  city  of  10,000  persons  ?  When  is  a  disease  pandemic  ?  When  en- 
demic ?  May  an  endemic  disease  become  epidemic  or  pandemic  ? 

What  other  peculiarities  do  contagious  and  infectious  diseases  pos- 
sess ?  What  diseases  have  the  longest  period  of  incubation  ?  What  ones 
the  shortest  ?  How  does  the  period  of  incubation  support  the  germ 
theory  ?  What  other  definite  period  has  each  of  these  diseases  ?  What 
is  the  usual  duration  of  a  case  of  typhoid  fever  ?  Of  scarlet  fever  ?  Of 
measles?  Does  this  support  the  germ  theory  ?  How  long  does  a  typhoid 
patient  remain  infective?  How  long  a  diphtheria  patient?  A  scarlet- 
fever  patient  ?  (See  chapters  on  School  Hygiene  and  Quarantine.)  Upon 
what  dqes  the  clanger  and  period  of  infectiveness  depend  ?  Are  these 
diseases  all  likely  to  confer  immunity  against  future  attacks  ?  Which 
are  most  likely  to  do  this  ? 


(323) 


CHAPTER  XIX. 

HISTORY  OF  EPIDEMIC  DISEASES. 

AN  important  part  of  the  knowledge  of  the  sanitarian  is 
that  which  relates  to  the  history  of  the  great  epidemic  diseases 
which  have  at  various  periods  devastated  large  areas  of  the  in- 
habited world.  In  this  chapter  the  history  of  these  diseases  will 
be  briefly  traced.  Although  some  of  these  diseases  have  nearly 
or  quite  ceased,  a  knowledge  of  their  habits  and  of  the  causes 
that  finally  led  to  their  extinction  is  of  great  value,  for  the  reason 
that  the  principles  and  measures  of  prevention  which  were 
effective  in  times  past  are  the  same  which  must  apply  at  pres- 
ent and  in  the  future.  Hence,  time  spent  in  looking  back  over 
the  fields  traversed  and  noting  victories  won  will  not  be  wasted. 

The  epidemic  diseases  which  will  here  claim  attention  are 
the  Oriental  plague,  the  sweating  sickness,  small-pox,  Asiatic 
cholera ;  typhus,  typhoid,  scarlet,  relapsing,  and  yellow  fevers ; 
diphtheria,  dengue,  epidemic  influenza,  and  syphilis.  In  addi- 
tion, some  information  will  be  given  on  certain  of  the  diseases 
of  animals  transmissible  to  man.  Among  these  are  sheep-pock, 
actinomycosis,  bovine  tuberculosis  (perlsucht),  rabies,  anthrax 
(milzbrand),  and  glanders. 

THE  ORIENTAL  PLAGUE. 

The  Oriental  plague,  bubonic  plague,  the  black  death,  or 
simply  the  "  plague,"  or  great  pestilence,  overtopping  in  its 
fatality  all  other  pestilences,  is  mentioned  by  a  number  of  the 
Greek  and  Latin  medical  authors.  The  first  account  which 
clearly  refers  only  to  this  disease  is  given  by  Procopius.  Ac- 
cording to  this  and  other  contemporary  authors,  the  disease  be- 
gan to  spread  in  the  year  542  from  Lower  Egypt,  passing  in  one 
direction  along  the  coast  of  Northern  Africa,  and  in  the  other 

(325) 


326  TEXT-BOOK   OF   HYGIENE. 

invading  Europe  by  way  of  Syria  and  Palestine.  In  the  course 
of  the  succeeding  years  this  pandemic  reached  "  the  limits  of  the 
inhabited  earth,"  in  the  language  of  the  writers  of  the  day.  The 
disease  prevailed  about  half  a  century,  and  produced  the  greatest 
devastation  wherever  it  appeared.  "  Cities  were  devastated,  the 
country  converted  into  a  desert,  and  the  wild  beasts  found  an 
asylum  in  the  abandoned  haunts  of  man."1 

The  plague  is  an  acute  infectious  disease,  which  is  char- 
acterized by  an  affection  of  the  lymphatic  system,  i.e.,  inflam- 
mation and  swelling  of  the  external  and  internal  lymphatic 
glands.  Accessory  symptoms  are  petechial  spots  upon  the  skin, 
and  haemorrhages  from  various  organs,  as  the  stomach,  nose, 
kidneys,  rectum,  and  uterus.  Those  attacked  suffer  in  varied 
degrees  of  intensity.  In  some,  a  fulminant  form  occurs  which 
carries  off  the  patient  within  three  days ;  there  is  another  class 
of  cases  in  which  buboes  develop,  with  accompanying  fever  and 
haemorrhages;  and,  finally,  a  light  form,  rarely  fatal,  in  which 
only  the  local  symptoms  are  manifested.  In  the  great  pan- 
demic of  the  plague  in  the  fourteenth  century  cough  and  bloody 
expectorations  were  very  frequent.  In  the  later  epidemics 
haemorrhage  from  the  lungs  has  been  rarely  noticed  as  a  symptom. 

About  the  middle  of  the  fourteenth  century  the  bubonic 
plague  made  a  second  incursion  into  Europe  from  its  home  in 
the  East.  A  most  graphic  description  of  its  ravages  is  given  by 
Boccaccio  in  the  "  Decameron."  This  author  states  that  in  1359, 
"  between  March  and  July  following,  according  to  authentic 
reckonings,  upward  of  100,000  souls  perished  in  the  city 
(Florence) ;  whereas,  before  that  calamity  it  was  not  supposed 
to  contain  so  many  inhabitants." 

This  terrible  epidemic  was  forcibly  characterized  by  its  com- 
mon name,  "  the  black  death."  Hecker  estimates  that  during  its 
continuance,  from  1347  to  1351,  25,000,000— one-fourth  of  the 
probable  total  population  of  Europe — died.  In  various  cities 
the  mortality  was — in  London,  100,000 ;  in  Paris,  50,000  ;  in 

1  Warnefried,  quoted  by  Hirsch,  Hist-Geographische  Pathologic,  I,  p.  350. 


THE   ORIENTAL   PLAGUE.  327 

Venice,  100,000  ;  in  Avignon,  60,000  ;  in  Marseilles,  16,000,  in 
one  month.  It  was  said  that  in  all  England  scarcely  a  tenth 
part  of  the  population  escaped  death  from  the  disease. 

The  moral  effects  of  this  great  pandemic  of  the  plague  were 
hardly  less  deplorable  than  the  physical.  Religious  fanaticism 
hold  full  sway  throughout  Europe,  finding  its  vent  in  all  manner 
of  excesses.  The  so-called  Brotherhood  of  the  Cross,  otherwise 
known  as  the  Order  of  Flagellants,  which  had  arisen  in  the 
thirteenth  century,  but  had  been  suppressed  by  the  ecclesiastical 
authorities,  was  revived  during  the  black  pestilence,  and  large 
numbers  of  these  religious  enthusiasts  roamed  through  the 
various  countries  on  their  great  pilgrimages.  Their  power  in- 
creased to  such  a  degree  that  Church  and  State  were  forced  to 
combine  for  their  suppression.  One  consequence  of  this  fanat- 
ical frenzy  was  the  persecution  of  the  Jews.  These  were  accused 
of  being  the  cause  of  every  evil  that  befell  mankind,  and  many 
were  put  to  death. 

In  the  fifteenth  and  sixteenth  centuries  the  plague  was 
generally  diffused  throughout  Europe,  and  in  the  second  third 
of  the  seventeenth  century  its  final  incursion  into  the  Occident 
took  place.  The  great  epidemic  in  London,  so  graphically  de- 
scribed by  Defoe,1  occurred  in  1665.  In  the  early  part  of  the 
eighteenth  century  (1720)  the  plague  visited  Marseilles  and 
Toulon  ;  from  1769  to  1772  it  was  epidemic  in  Moldavia,  AVal- 
lachia,  Poland,  and  Southern  Russia ;  near  the  close  of  the  last, 
and  in  the  beginning  of  the  present  century,  in  Transylvania, 
Wallachia,  Southern  Russia,  and  Greece.  Very  recently,  in 
1878  and  1879,  and  in  1885,  the  plague  threatened  a  new 
irruption  into  European  territory,  being  epidemic  in  the  district 
of  Astrachan,  on  the  Caspian  Sea.  At  the  date  of  writing 
(August,  1894)  it  is  reported  epidemic  in  certain  parts  of  China. 

Although  the  bubonic  plague  has  never  been  observed  in 
America,  and  has  spared  Europe  almost  entirely  during  the  present 
century,  it  still  persists  in  certain  countries  of  Asia  and  Africa, 
especially  in  Arabia,  Mesopotamia,  Persia,  and  the  coast  of  Tripoli. 

1  Journal  of  the  Plague  in  London. 


328  TEXT-BOOK    OF    HYGIENE. 

The  older  authors  ascribed  the  origin  of  the  plague  to 
various  real  or  supposed  conditions.  Comets,  conjunctions  of 
the  planets,  "  God's  just  punishment  for  our  sins,"  and  similar 
causes  were  advanced  to  account  for  the  outbreaks.  Most  of  the 
writers  of  the  post-medieval  and  modern  epochs  ascribed  the 
disease  to  meteorological  conditions.  Observing  the  fact  that  the 
plague  never  advanced  into  the  torrid  zone,  and  that  an  epidemic 
generally  ended  with  the  advent  of  hot  weather,  a  high  tempera- 
ture was  believed  to  be  incompatible  with  the  existence  of  an 
epidemic,  and  a  cold  or  temperate  climate  was  considered  neces- 
sary to  an  outbreak  of  the  disease.  The  exceptions  to  the  rule 
are  so  numerous,  however,  that  the  theory  of  the  climatic  or 
meteorological  origin  of  the  plague  failed  of  support.  The  theory 
which  ascribed  the  origin  of  the  epidemics  to  the  influence  of 
certain  hot  and  dry  winds  or  a  high  humidity  is  also  insufficient. 
Certain  geological  formations  have  been  supposed  to  furnish 
favorable  conditions  for  the  development  of  the  disease.  Facts 
show,  however,  that  the  disease  has  prevailed  epidemically  and 
endemically  in  various  parts  of  the  earth,  and  of  the  most  diverse 
geological  character.  A  certain  elevation  above  sea-level  has 
been  held  to  confer  immunity,  but  recent  observations  in  India 
show  that  this  belief  is  unfounded,  even  places  at  an  elevation 
of  10,000  feet  above  sea-level  giving  no  security  against  attack. 

There  is,  however,  one  point  upon  which  nearly  all  writers 
who  mention  the  fact  at  all  agree.  This  is  that  hid  hygienic 
conditions  are  always  present  where  plague  prevails.  Nearly  all 
observers  who  have  left  their  impressions  on  record  mention  the 
accumulation  of  filth  in  the  houses  and  streets,  deficient  removal 
of  excrementitious  and  other  sewage  matters,  crowding  and  im- 
perfect ventilation  of  dwellings  as  causes  favoring  the  develop- 
ment and  spread  of  the  pestilence.  All  point  out  the  necessity 
of  the  removal  of  these  evils  as  the  most  important  prophylactic 
measure  to  be  adopted,  and  all  of  them  call  attention  to  the  fact 
that  those  classes  of  the  population  most  exposed  to  these  unfa- 
vorable influences  suffer  most  from  the  violence  of  the  epidemic. 


THE   ORIENTAL    PLAGUE.  329 

The  later  reports  of  the  epidemics  in  Persia,  India,  Mesopo- 
tamia, and  Russia  agree  in  asserting  that  nothing  seems  to  have 
promoted  the  epidemic  and  endemic  prevalence  of  the  plague  so 
much  as  the  material  wretchedness  of  the  inhabitants  of  those 
countries.  In  a  collection  of  papers  on  the  plague,  printed  by 
a  British  Parliamentary  Commission  in  1879,  occur  these  state- 
ments :  "  The  filth  is  everywhere,"  says  Mr.  Rennie,  one  of  the 
reporters, — "  in  their  villages,  their  houses,  and  their  persons. 
Their  dwellings  are  generally  low  and  ill-ventilated,  except 
through  their  bad  construction ;  and  the  advantage  of  the 
natives  in  other  parts  of  India,  of  living  in  the  open  air,  is  lost 
to  the  villagers  of  Ghurwal,  from  the  necessity  of  their  crowding 
together  for  mutual  warmth  and  shelter  against  the  inclemency 
of  the  weather"."  Dr.  Dickson,  reporting  on  the  plague  in  Irak 
Arabi  in  1876,  says:  "  The  most  palpable  and  evident  of  all  the 
causes  which  predispose  an  individual  to  an  attack  of  plague 
during  an  epidemic  outbreak  is  poverty.  No  other  malady  shows 
the  influence  of  this  factor  in  so  striking  a  degree ;  so  much  so, 
indeed,  that  Dr.  Cabiadis  styles  the  plague  miserice  mortis.  In 
his  experience  (1876-77,  in  Bagdad)  he  found  that  the  poor 
were  seldom  spared,  the  wealthy  hardly  ever  attacked." 

The  manner  of  the  transmission  of  the  plague  is  generally 
by  prolonged  inhalation  of  an  infected  atmosphere.  Hence,  it 
may  be  termed  an  infectious  disease,  although  it  is  not  improbable 
that  it  may  be  communicated  by  direct  contact  botli  of  persons 
and  of  fomites.  It  is  probably  due  to  a  micro-organism,  although 
no  demonstration  of  the  latter  has  been  furnished  up  to  the 
present  time. 

These  considerations  indicate  the  measures  of  prevention 
to  be  adopted.  They  consist  of  a  rigid  quarantine  of  persons 
and  fomites,  prompt  and  complete  isolation  of  infected  individuals 
and  localities,  and  destruction  (by  fire)  or  thorough  disinfection 
by  steam  or  sulphurous-acid  gas  of  all  materials  capable  of  con- 
veying the  virus  of  the  disease. 

1  Hirscb,  op.  clt.,  p.  370. 


330  TEXT-BOOK   OF   HYGIENE. 

THE    SWEATING    SICKNESS. 

This  name  concisely  characterizes  an  epidemic  disease 
which  for  the  first  time  appeared  in  the  city  of  London  and 
other  parts  of  England  in  the  autumn  of  1485.  According  to 
Lord  Bacon,1  the  disease  began  about  the  21st  of  September 
and  lasted  until  near  the  end  of  October.  It  broke  out  a  second 
time  in  the  summer  of  1507;  a  third  time  in  July,  1518,  spread- 
ing in  the  course  of  six  months  throughout  England.  In  May, 
1529,  the  disease  made  its  appearance  again  in  the  latter  country, 
spreading  thence  over  a  great  part  of  the  continent  of  Europe. 
Another  very  malignant  epidemic  broke  out  in  the  spring  of 
1541,  lasting  through  the  summer,  and  limited  in  its  ravages  to 
England. 

With  this  last  outbreak,  in  1551,  this  disease  disappeared 
entirely  in  England  and  has  not  re-appeared  there  up  to  the 
present  day.  In  the  beginning  of  the  eighteenth  century,  how- 
•ever,  a  disease  very  similar  in  its  symptoms  and  course  broke  out 
in  Picardy  and  other  districts  of  Northern  France,  being  confined 
for  a  number  of  years  to  this  section  of  the  country.  Toward 
the  end  of  the  century  it  spread  to  the  south  of  France,  and 
since  that  time  has  appeared  epidemically  at  intervals,  195  dis- 
tinct outbreaks  having  been  observed  in  the  course  of  168  years, 
from  1718  to  1887.  The  disease  has  frequently  appeared  in  Italy 
since  1755,  and  in  various  parts  of  Germany  since  1801.  In 
Belgium  it  has  been  observed  at  a  few  places  within  the  present 
century. 

The  disease  appeared  suddenly,  often  at  night-time.  The 
patient  was  attacked  with  palpitation  of  the  heart,  dyspnoea, 
great  anxiety  and  oppression,  and  profuse  perspiration.  A 
miliary  eruption  often  appeared  on  the  skin.  In  favorable  cases 
these  symptoms  diminished  in  the  course  of  one  or  two  days,  the 
urinary  secretion,  which  had  been  suppressed,  was  restored,  and 
the  perspiration  became  gradually  less  free.  Recovery  ensued 
in  from  one  to  two  weeks.  In  grave  cases  there  were,  in  the 

1  History  of  Henry  VII. 


SMALL-POX.  331 

beginning  of  the  attack,  violent  headache,  delirium,  convulsions, 
followed  by  a  comatose  condition,  from  which  the  patients  rarely 
recovered. 

This  disease  is  undoubtedly  of  a  miasmatic,  infectious  nature, 
as  proved  by  its  rapid  spread  and  limitation  to  certain  localities. 
It  appears  most  frequently  in  the  spring  and  summer,  and  is 
nearly  always  observed  in  marshy  or  damp  localities.  Its  spread 
is  favored  by  a  high  temperature  and  humidity.  There  is  no 
apparent  connection  between  the  outbreaks  of  the  sweating 
sickness  and  overcrowding  or  other  insanitary  conditions;  in 
fact,  it  is  stated  by  numerous  observers,  both  old  and  recent,  that 
children,  the  aged,  and  generally  the'  poorer  classes  were  remark- 
ably exempt  from  the  disease.  The  recent  epidemic  in  France, 
in  1887,  was  investigated  by  Dr.  Brouardel,  Chantemesse,  and 
other  epidemiologists,  but  no  trustworthy  conclusions  as  to  the 
nature  of  the  disease  have  yet  been  reached. 

Since  the  first  appearance  of  Asiatic  cholera  in  France,  in 
1832,  an  apparently  intimate  connection  has  been  observed 
between  the  occurrence  of  that  disease  and  outbreaks  of  sweating 
sickness.  A  disease  strongly  resembling  the  sweating  sickness 
has  also  been  observed  in  India  in  districts  contiguous  to  places 
where  cholera  was  at  the  time  epidemic.1 

SMALL-POX. 

The  earliest  details  concerning  small-pox  are  derived  from 
certain  Chinese  records,  according  to  which  it  appears  that  this 
disease  was  known  in  China  upward  of  2000  years  ago.  It  was 
also  known  at  a  very  early  period  in  India.  It  is  believed  to 
have  been  introduced  into  Europe  in  the  second  century  by  a 
Roman  army  returning  from  Asia.  It  is  believed  that  the  Em- 
peror Marcus  Aurelius  died  of  small-pox,  which  prevailed  in  his 
army  at  the  time  of  his  death. 

The  first  distinct  references  to  small-pox  in  medical  literature 
occur  in  the  writings  of  Galen,  in  the  second  century.  Rhazes, 

1  Murray,  Madras  Quart.  Med.  Journ.,  1840-41.    Quoted  in  Hirsch,  loc.  cit.,  p.  83. 


332  TEXT-BOOK    OF   HYGIENE. 

in  the  ninth  century,  wrote  upon  the  disease,  describing  it  very 
accurately. 

The  almost  universal  susceptibility  to  small-pox  caused 
wide-spread  devastation  wherever  it  appeared  previous  to  the 
introduction  of  vaccination.  The  statement  is  made  that  in 
England,  in  the  last  century,  about  one  person  in  every  three 
was  badly  pock-marked.  The  mortality  from  the  disease  was 
exceedingly  great,  being,  in  the  latter  half  of  the  eighteenth 
century,  about  3000  per  million  of  inhabitants  annually. 

In  India  the  mortality  from  small-pox  has  been  exceedingly 
great  within  the  last  twenty  years.  From  1866  to  1869,  140,000 
persons  died  in  the  Presidencies  of  Bombay  and  Calcutta,  having 
a  population  of  about  40,000,000.  Several  years  later,  from 
1873  to  1876,  700,000  died  from  this  disease. 

China,  Japan,  Cochin  China,  the  islands  of  the  China  Sea, 
and  Corea  are  frequently  ravaged  by  small-pox.  In  the  latter 
country  nearly  all  the  inhabitants  are  said  to  bear  evidence  of 
an  attack  of  the  disease. 

The  Samoyedes,  Ostiaks,  and  other  natives  of  Eastern  Siberia 
have  frequently  suffered  from  devastating  epidemics.  In  Kamt- 
chatka  the  disease  was  introduced  in  1767,  and  produced 
frightful  ravages.  Many  villages  were  completely  depopulated. 

In  Mexico  small-pox  was  introduced  by  the  Spaniards  in 
1520.  In  a  short  time  it  carried  off  over  3,500.000  of  the 
natives.  In  the  Marquesas  Islands  one-fourth  of  the  inhabitants 
have  fallen  victims  to  the  disease  since  1863. 

It  was  first  introduced  into  the  Sandwich  Islands  in  1853, 
and  carried  off  8  per  cent,  of  the  natives. 

Australia,  Tasmania,  New  Zealand,  and  the  Fejee  Archi- 
pelago remain  exempt  to  the  present  day  from  small-pox.  It  has 
several  times  been  carried  to  Australia  by  vessels,  but  has  always 
been  promptly  checked  by  the  vigilance  of  the  authorities. 

On  the  Western  Hemisphere  small-pox  was  unknown  before 
the  arrival  of  the  European  conquerors.  It  has  been  spread  by 
the  whites  or  imported  African  slaves  to  nearly  all  the  Indian 


SMALL-POX.  333 

tribes  of  both  continents.  When  it  attacks  large  communities 
unprotected  by  previous  outbreaks  of  the*  disease,  or  by  inocula- 
tion or  vaccination,  its  ravages  are  frightful.  The  mortality  of 
unmodified  small-pox  is  usually  between  30  and  40  per  cent. 

Small-pox  is  a  highly  contagious  and  infectious  disease. 
It  is  produced  by  actual  contact,  by  inoculation,  and  by  inhaling 
an  atmosphere  charged  with  the  poison.  In  order  to  cause  an 
outbreak  two  factors  are  necessary :  first,  a  number  of  individuals 
susceptible  to  this  disease,  and,  second,  the  introduction  into  the 
body,  in  some  manner,  of  the  virus  upon  which  it  depends. 

Small-pox  is  spread  from  (1)  persons  sick  with  the  disease; 
(2)  others,  not  themselves  sick  or  susceptible,  but  coming  in 
contact  with  the  poison ;  (3)  fomites  (cotton,  wool,  etc.),  and  (4) 
the  bodies  of  persons  dead  with  small-pox.  It  is  also  probable 
that  the  air  in  the  immediate  vicinity  of  a  person  sick  with  small- 
pox becomes  charged  with  the  poison  and  able  to  convey  the 
disease.  It  is  at  present  impossible  to  fix  the  distance  to  which 
this  infectiousness  of  the  air  extends,  but  it  does  not  ordinarily 
reach  beyond  the  room  in  which  the  patient  is  confined. 

It  is  a  fact  of  common  observation  that  the  darker  races 
are  more  commonly  attacked,  and  the  disease  is  likewise  more 
fatal  among  them.  The  mortality  among  negroes  is  much  larger 
than  among  other  races. 

It  is  a  current  belief  that  small-pox  is  only  contagious  after 
the  development  of  the  pustules.  This  is  a  serious  error.  It  is 
probably  contagious  in  all  stages  of  the  disease ;  certainly  as 
early  as  the  first  appearance  of  the  eruption,  and  probably  even 
in  the  stage  of  preliminary  fever. 

One  attack  of  small-pox  usually  confers  immunity  from  the 
disease  for  life.  This  rule  has  its  exceptions,  however,  which,  if 
not  numerous,  are  yet  not  infrequent.  The  author  has  seen  a 
case  in  which  the  patient  suffered  from  a  third  attack  of  the 
disease. 

The  popular  belief,  that  persons  suffering  from  any  acute 
or  chronic  disease  are  less  liable  to  be  attacked  by  small-pox 


334  TEXT-BOOK   OF   HYGIENE. 

than  those  at  the  time  in  good  health,  is  erroneous.  On  the 
contrary,  the  subjects  of  chronic  disease,  such  as  consumption  or 
dyspepsia,  are  much  more  liable  to  succumb  to  an  attack  of 
small-pox  than  persons  previously  in  good  health. 

It  is  true,  however,  that  individuals  suffering  from  some 
other  acute  infectious  disease,  like  scarlet  fever,  measles,  typhoid 
fever,  etc.,  are  generally,  though  not  absolutely,  exempt  from 
an  attack  of  small-pox  during  the  time  they  are  sick  with  such 
disease.  But  if  they  are  exposed,  after  recovery,  to  the  small- 
pox infection,  their  liability  to  an  attack  is  as  great  as  in  those 
who  have  not  passed  through  a  similar  disease.  A  number  of 
cases  have  been  reported  by  Curschmann,1  in  which  infection 
by  small-pox  took  place  on  the  day  in  which  convalescence  from 
typhoid  fever  was  established. 

The  author  has  reported  a  case2  in  which  the  patient  passed 
through  an  attack  of  erysipelas  during  the  incubative  stage  of 
small-pox.  From  all  the  evidence  attainable,  the  incubative  stage 
was  not  prolonged  by  the  intercurrent  erysipelas. 

Epidemics  of  small-pox  usually  begin  in  the  autumn  or 
winter,  and  lessen  in  violence  as  warmer  weather  approaches. 
The  spread  of  the  disease  is  slow  at  first,  increasing  in  rapidity 
as  the  foci  of  infection  multiply. 

When  the  poison  is  imported  into  a  community  late  in  the 
spring  or  during  the  summer,  the  increase  in  the  number  of 
cases  is  exceedingly  gradual  until  colder  weather  sets  in.  If  it 
is  introduced  during  the  winter,  the  disease  spreads  much  more 
rapidly,  but  decreases,  and  sometimes  almost  disappears,  during 
the  summer.  On  the  return  of  cold  weather,  however,  the  epi- 
demic starts  out  with  a  new  lease  of  activity  and  presents  great 
difficulties  to  its  restriction. 

A  number  of  observers,  among  whom  are  Coze  and  Feltz, 
Lugenbuhl,  Weigert,  Strauss,  Garre,  and  Wolff,  claim  to  have 
discovered  specific  organisms  in  the  contents  of  variolous  pustules, 
in  the  blood  of  patients  with  the  disease,  and  in  vaccine  lymph. 

1  Ziemssen's  Cyclopaedia,  vol.  ii.  '  Medical  News,  July  7, 1883. 


SMALL-POX. 

Expert  bacteriologists  are,  however,  not  willing  to  accept  the 
evidence  hitherto  furnished  as  conclusive. 

Inoculation. — The  prevention  or  restriction  of  such  a  uni- 
versal and  fatal  pestilence  as  small-pox  is  a  matter  of  the  deepest 
importance.  The  first  attempt  to  limit  its  fatality  dates  from  the 
end  of  the  seventeenth  century.  It  became  generally  known  in 
Europe,  about  the  year  1700,  that  the  intentional  inoculation  of 
variolous  matter  into  healthy  individuals  induced  an  attack  of 
the  disease,  which  generally  ran  through  its  various  stages  with 
less  virulence  than  when  the  disease  was  contracted  in  the  usual 
manner.  In  1716  and  1717  two  papers  were  published  in  the 
"  Transactions  of  the  Royal  Society  of  England"  giving  an  ac- 
count of  the  process  of  inoculation.  The  attention  of  the  public 
was  especially  directed  to  the  matter,  however,  by  the  famous 
letter  of  Lady  Mary  Wortley  Montagu,  dated  April  1,1717.  This 
letter  is  as  follows1:  "Apropos  of  distempers,  I  am  going  to  tell 
you  a  thing  that  will  make  you  wish  yourself  here.  The  small- 
pox, so  fatal  and  so  general  amongst  us,  is  here  entirely  harm- 
less by  the  invention  of  ingrafting,  which  is  the  term  they  give 
it.  There  is  a  set  of  old  women  who  make  it  their  business  to 
perform  the  operation  every  autumn,  in  the  month  of  September, 
when  the  great  heat  is  abated.  People  send  to  one  another  to 
know  if  any  of  their  family  has  a  mind  to  have  the  small-pox ; 
they  make  parties  for  this  purpose,  and  when  they  are  met — 
commonly  fifteen  or  sixteen  together — the  old  woman  comes 
with  a  nut-shell  full  of  the  matter  of  the  best  sort  of  small-pox, 
and  asks  what  veins  you  please  to  have  opened.  She  immediately 
rips  open  that  you  offer  to  her  with  a  large  needle — which  gives 
you  no  more  pain  than  a  common  scratch — and  puts  into  the 
vein  as  much  matter  as  can  lie  upon  the  head  of  her  needle, 
and  after  that  binds  up  the  little  wound  with  a  hollow  bit  of 
shell ;  and  in  this  manner  opens  four  or  five  veins.  The  Grecians 
have  commonly  the  superstition  of  opening  one  in  the  middle 
of  the  forehead,  one  in  each  arm,  and  one  on  the  breast,  to  make 

1  The  letter  is  addressed  to  Mrs.  S.  C.  (Sarah  Chiswell). 


336  TEXT-BOOK    OF   HYGIENE. 

the  sign  of  the  cross ;  but  this  has  a  very  ill  effect,  all  these 
wounds  leaving  little  scars,  and  is  not  done  by  those  that  are 
not  superstitious,  who  choose  to  have  them  in  the  leg  or  that 
part  of  the  arm  that  is  concealed.  The  children  or  young  pa- 
tients play  together  all  the  rest  of  the  day,  and  are  in  perfect 
health  until  the  eighth.  Then  the  fever  begins  to  seize  them,  and 
they  keep  their  beds  two  days,  very  seldom  three.  They  have 
rarely  above  twenty  or  thirty  in  their  faces,  which  never  mark ; 
and  in  eight  days'  time  they  are  as  well  as  before  their  illness. 
Where  they  are  wounded  there  remain  running  sores  during 
the  distemper,  which  I  don't  doubt  is  a  great  relief  to  it.  Every 
year  thousands  undergo  this  operation ;  and  the  French  ambas- 
sador says  pleasantly :  '  They  take  the  small-pox  here  by  way  of 
diversion,  as  they  take  the  waters  in  other  countries.'  There  is 
no  example  of  any  one  that  has  died  in  it,  and  you  may  believe 
that  I  am  well  satisfied  of  the  safety  of  the  experiment,  since  I 
intend  to  try  it  on  my  dear  little  son. 

"I  am  patriot  enough  to  take  pains  to  bring  this  useful 
invention  into  fashion  in  England;  and  I  should  not  fail  to 
write  to  some  of  our  doctors  very  particularly  about  it,  if  I  knew 
any  of  them  that  I  thought  had  virtue  enough  to  destroy  such  a 
considerable  branch  of  their  revenue  for  the  gtfod  of  mankind. 
But  that  distemper  is  too  beneficial  to  them  not  to  expose  to  all 
their  resentment  the  hardy  wight  that  should  undertake  to  put 
an  end  to  it.  Perhaps,  if  I  live  to  return,  I  may,  however,  have 
courage  to  war  with  them." 

Soon  after  the  date  of  this  letter  the  writer's  son  was 
inoculated  in  Turkey,  and  four  years  later  her  daughter  also, 
being  the  first  subject  inoculated  in  England.  The  practice 
soon  became  popular,  but  several  fatal  cases  among  prominent 
families  brought  it  into  disrepute,  and  for  about  twenty  years 
very  few  inoculations  were  made  in  England.  It  was  revived 
about  the  middle  of  the  century  by  the  founding  of  a  small-pox 
and  inoculation  hospital  in  London.  This  continued  in  opera- 
tion until  1822.  The  records  of  this  institution  showed  that  only 


SMALL-POX.  337 

three  in  a  thousand  died  of  the  disease  thus  communicated.  The 
practice  has  now  fallen  into  desuetude,  being  superseded  by  vac- 
cination and  prohibited  by  law  in  England. 

Inoculation  was  introduced  into  this  country  in  1721  by 
Dr.  Zabdiel  Boylston,  of  Boston,  who  had  his  attention  directed 
to  the  practice  by  Cotton  Mather,  the  eminent  divine.1  During 
1721  and  1722,  286  persons  were  inoculated  by  Boylston  and 
others  in  Massachusetts,  and  6  died.  These  fatal  results  ren- 
dered the  practice  unpopular,  and  at  one  time  the  inoculation 
hospital  in  Boston  was  closed  by  order  of  the  Legislature. 
Toward  the  end  of  the  century  an  inoculating  hospital  was  again 
opened  in  that  city. 

Early  in  the  eighteenth  century  inoculation  was  extensively 
practiced  by  Dr.  Adam  Thomson,  of  Maryland,  who  was  instru- 
mental in  spreading  a  knowledge  of  the  practice  throughout 
the  Middle  States.2 

In  China  and  India,  and  perhaps  other  eastern  countries, 
inoculation  was  practiced  at  a  very  early  period. 

The  inoculation  of  variolous  matter,  although  it  mitigated 
to  a  very  great  degree  the  attack  of  small-pox  following,  had 
one  very  serious  objection,  aside  from  the  small  death-rate  which 
was  a  direct  consequence  of  it.  This  was  the  fact  that  inocula- 
tion always  produced  small-pox,  and  thus  assisted  in  propagating 
the  disease;  for,  however  mild  the  induced  disease  might  be,  the 
inoculated  individual  was  liable  to  communicate  small-pox  to 
others  in  the  most  virulent  form.  Hence,  nothing  short  of  uni- 
versal inoculation,  which  was  manifestly  impracticable,  would 
succeed  in  reducing  the  danger  from  the  disease. 

Vaccination. — It  had  been  noticed  at  various  times  that  a 
pustular  disease  which  sometimes  appears  on  the  udders  of  cows, 
called  cow-pox,  had  not  infrequently  been  transmitted  to  the 
hands  of  the  dairy-maids  and  others  having  much  to  do  with 

'Dr.  John  R.  Quinan  (M<1.  Med.  Journ.,  June 23 and  30,  1883)  believes  the  claim  of  Dr. 
Boylston  to  be  the  first  American  inoculator  open  to  question.  The  evidence  presented  is,  how- 
ever, insufficient  to  discredit  the  claim  of  the  Koston  physician. 

1  See  Quinan,  loc.  cil.,  p.  114. 

22 


338  TEXT-BOOK   OF   HYGIENE. 

cows.  In  course  of  time  it  was  also  noticed  that  persons  who 
had  been  thus  attacked  never  suffered  from  small-pox.  This 
protective  power  of  cow-pox  was  known  as  early  as  1713,  and 
in  1774  Benjamin  Jesty,  a  Gloucestershire  farmer,  performed 
vaccination  for  the  first  time  on  record,  inoculating  his  wife  and 
two  sons  with  cow-pox  matter  as  a  protection  against  small-pox. 

It  is  stated  that  when  it  became  known  that  Jesty  had 
vaccinated  his  wife  and  sons,  "his  friends  and  neighbors,  who 
had  hitherto  looked  upon  him  with  respect,  on  account  of  his 
superior  intelligence  and  honorable  character,  began  to  regard 
him  as  an  inhuman  brute,  who  could  dare  to  practice  experi- 
ments upon  his  family,  the  sequel  of  which  would  be,  as  they 
thought,  their  metamorphosis  into  horned  beasts.  Consequently 
the  worthy  farmer  was  hooted  at,  reviled,  and  pelted  whenever 
he  attended  the  markets  in  his  neighborhood."1 

In  1791  a  school-teacher  in  Holstein  also  inoculated  three 
boys  with  the  matter  of  cow-pox,  but  nothing  is  known  of  the 
subsequent  history  of  these  cases. 

Although  the  above  facts  are  clearly  established,  it  is  to 
Edward  Jenner,  a  modest  country  doctor  of  Berkeley,  in  the 
county  of  Gloucester,  England,  that  the  merit  of  demonstrat- 
ing the  protective  power  of  cow-pox  against  small-pox,  and  of 
diffusing  a  knowledge  of  this  fact,  is  due.  Jenner  had  his  atten- 
tion directed  to  the  asserted  protection  conferred  by  cow-pox 
during  the  period  of  his  apprenticeship.  After  a  residence  in 
London  as  a  pupil  of  John  Hunter,  he  returned  to  the  country 
to  practice  his  profession.  About  the  year  1776  he  began 
studying  the  question,  and  gathering  evidence  of  the  protection 
afforded  against  small-pox  by  the  accidental  inoculation  of  cow- 
pox  virus.  For  twenty  years  he  studied  the  subject,  patiently 
awaiting  an  opportunity  to  put  his  belief  to  the  test  of  experi- 
ment. On  the  14th  of  May,  1796,  he  made  his  first  vaccination 
on  a  boy  named  James  Phipps.  Six  weeks  later  he  inoculated 
this  boy  with  variolous  matter,  but  without  success,  no  small- 

1  London  Lancet,  September  13,  1862. 


SMALL-POX.  339 

pox  resulting.  Two  years  later  he  published  his  pamphlet, 
.MI titled  "  An  Inquiry  into  the  Causes  and  Effects  of  the  Variola 
Vaccm.se,  etc.,"  in  which  he  detailed  his  observations  and  experi- 
ments. This  publication  produced  a  great  sensation  in  the 
medical  world,  and,  although  much  opposition  was  at  first 
manifested  toward  his  views,  he  soon  gained  many  adherents. 
*  Vaccination,  as  the  operation  for  the  inoculation  of  cow-pox 
virus  is  termed,  was  rapidly  introduced  into  all  civilized  countries, 
and  soon  demonstrated  its  good  effects  by  greatly  restricting  the 
prevalence  of  small-pox.  It  is  generally  believed  that  the  first 
one  to  practice  vaccination  in  this  country  was  Dr.  Benjamin 
Waterhouse,  of  Boston,  in  the  summer  of  1800;  but  Dr.  John 
R.  Quinan  has  recently  shown l  that  vaccination  was  introduced 
into  Maryland,  by  Dr.  John  Crawford  and  Dr.  James  Smith,  at 
least  as  early  as  the  date  generally  assigned  for  its  introduction 
into  Massachusetts. 

It  was  believed  by  Dr.  Jenner,  and  was  afterward  conclu- 
sively shown  by  a  number  of  distinguished  experimenters,  that 
vaccinia,  as  the  disease  produced  by  cow-pox  inoculation  was 
called,  was  merely  a  modification  of  small-pox  as  it  existed  in 
the  cow.  Small-pox  virus,  when  inoculated  upon  the  cow, 
produced  cow-pox;  but  the  latter,  re-inoculated  upon  man, 
produced  cow-pox  (vaccinia),  and  not  small-pox.  Sheep-pock 
and  horse-pock,  or  "  grease,"  are  probably  merely  modifications 
of  the  disease  produced  by  inoculating  small-pox  into  those 
animals. 

When  cow-pox  virus  is  successfully  inoculated  into  the 
human  system — that  is,  when  a  person  is  successfully  vaccinated 
— the  following  local  and  general  symptoms  are  observed : — 

In  the  case  of  a  primary  vaccination,  i.e.,  where  the 
individual  has  not  been  previously  vaccinated  or  attacked  by 
small-pox,  the  point  where  the  vaccination  is  made  shows  no 
particular  change  for  the  first  two  days.  If  the  vaccination  is 
successful,  a  small,  reddish  papule  appears  by  the  third  day, 

1  Quinan,  loc.  cit.,  pp.  118, 131. 


340  TEXT-BOOK   OF   HYGIENE. 

which,  by  the  fifth  or  sixth  day,  has  become  a  distinct  vesicle  of 
a  bluish-white  color,  with  a  raised  edge  and  a  peculiar,  central, 
cup-like  depression  called  the  umbilication.  By  the  eighth  day 
this  vesicle  has  become  plump,  round,  and  pearl-colored,  the 
central  umbilication  being  still  more  marked.  At  this  time  a 
red,  inflamed  circle,  called  the  areola,  appears,  surrounding  the 
vesicle  and  extending  usually  in  a  radius  of  from  ^  to  2  inches* 
when  fully  developed.  This  inflammatory  ring  is  usually  pretty 
firm,  and  there  is  more  or  less  general  fever  and  often  enlarge- 
ment and  tenderness  of  the  axillary  glands.  After  the  tenth 
day  the  areola  begins  to  fade,  and  the  contents  of  the  vesicle 
dry  into  a  hard,  brownish  crust  or  scab,  which  falls  off  between 
the  twentieth  and  twenty-fourth  days,  leaving  a  punctated  scar, 
which  gradually  becomes  white. 

When  the  vaccinia  has  passed  through  all  of  these  stages, 
especially  if  the  vesicle  filled  with  pearly  lymph,  and  the  areola 
have  been  well  developed,  the  vaccination  may  be  considered  a 
success,  and  the  individual  protected  against  small-pox  for  a 
number  of  years,  if  not  for  life.  Recently  the  doctrine  has  been 
strongly  advocated  that  vaccination  is  not  absolutely  protective 
until  a  subsequent  inoculation  of  vaccine  fails  to  "  take." 
According  to  this  view,  vaccination  should  be  repeated  until  it 
fails  any  longer  to  exhibit  any  local  reaction.  When  this  has 
.been  attained  the  individual  may  be  considered  absolutely 
protected  for  life.  Theoretically,  this  view  has  much  in  its 
favor,  but  there  is,  as  yet,  not  sufficient  evidence  to  establish  it 
as  a  law. 

It  may  be  stated  as  an  established  fact  that  vaccination, 
although  carefully  performed  and  successful,  does  not  confer 
absolute  immunity  from  small-pox  for  life.  The  protective 
power  seems  to  wear  out  after  a  time  and  the  individual  then 
again  becomes  susceptible  to  small-pox.  An  attack  of  small- 
pox in  a  vaccinated  individual  is,  however,  nearly  always  much 
milder  than  where  there  had  been  no  vaccination.  There  is  no 
fact  in  the  entire  range  of  medicine  better  established  than  this : 


SMALL-POX.  341 

that  small-pox  in  vaccinated  persons  is  a  much  less  dangerous 
disease  than  typhoid  fever,  while  in  unvaccinated  cases  the 
mortality  ranges  from  30  to  40  per  cent.  An  approximate 
guide  to  the  beneficent  influence  of  vaccination  upon  the 
mortality  from  small-pox  is  furnished  by  a  table  in  Seaton's 
report  on  vaccination.  Before  the  introduction  of  vaccination 
the  mortality  from  small-pox,  per  million  of  inhabitants  of  Eng- 
land, was  nearly  3000  per  year.  After  the  introduction  of  vac- 
cination the  mortality  was  reduced  to  310  per  million  per  year. 

The  most  remarkable  and  convincing  statistical  evidence 
on  the  question  is  given  by  Drs.  Seaton  and  Buchanan,  of 
England.  During  the  small-pox  epidemic  in  London,  in  1863, 
they  examined  over  50,000  school-children,  and  found  among 
every  thousand  without  evidence  of  vaccination  360  with  scars 
of  small-pox,  while  of  every  thousand  presenting  some  evidence 
of  vaccination  only  1.78  had  any  such  traces  of  small-pox  to 
exhibit.1  The  reliability  of  general  mortality  statistics  may  be 
called  in  question — in  some  cases,  with  justice ;  but  the  signifi- 
cance of  these  figures  cannot  be  evaded. 

The  upper  and  outer  surface  of  the  arm  is  usually  chosen 
as  the  point  where  the  virus  is  inserted,  although  any  part  of 
the  body  which  can  be  protected  against  friction,  or  other 
mechanical  irritation,  may  be  selected.  The  method  varies 
slightly  in  the  hands  of  different  vaccinators.  The  two  methods 
most  frequently  in  use  are  scarification  and  erasion.  The 
former  method  has  the  indorsement  of  Mr.  Seaton,  the  high 
English  authority.  The  method  of  erasion — scraping  off  the 
epidermis  until  the  papillary  layer  of  the  skin  is  laid  bare — is 
now  most  frequently  used  in  this  country.  The  best  instrument 
to  use  is  a  clean  thumb-lancet ;  in  default  of  this,  an  ordinary 
sewing-needle  answers  well.  Where  animal  vaccine  is  used, 
the  ivory  slip  or  sharpened  quill  may  also  be  used  with  satis- 
faction to  make  the  scarification  or  erasion.  Whatever  instru- 
ment is  used,  it  should  always  be  kept  perfectly  clean. 

1  Seaton,  "  Vaccination,"  in  Reynolds's  System  of  Medicine,  vol.  i,  p.  291.    Second  edition. 


342  TEXT-BOOK   OF   HYGIENE. 

A  point  of  vital  importance  is  that  which  relates  to  the 
proper  age  at  which  children  should  be  vaccinated.  Ordinarily, 
vaccination  should  be  performed  within  the  first  six  months  of 
life.  In  time  of  danger  from  a  threatened,  or  in  the  presence 
of  an  actual,  epidemic,  infants  may  be  vaccinated  when  only  1 
day  old. 

In  order  to  secure  permanent  protection  against  small-pox, 
revaccination  should  be  performed  after  a  certain  interval. 
Some  place  the  period  at  which  this  second  vaccination  should 
be  done  at  five  years,  while  others  allow  a  longer  interval — 
seven,  eight,  or  ten  years.  The  law  of  Prussia  is  that  every 
child  that  has  not  already  had  small-pox  must  be  vaccinated 
within  the  first  year  of  its  life,  and  every  pupil  in  a  public  or 
private  institution  is  to  be  revaccinated  during  the  year  in 
which  his  or  her  twelfth  birthday  occurs. 

This  law  was  passed  in  1874.  Prior  to  this  time  the 
mortality  from  small-pox  was  15  to  20  per  100,000  of  the 
population.  Since  the  law  was  enacted  the  small-pox  mortality 
has  varied  from  0.3  to  3.6  per  100,000.  Not  a  single  death 
from  small-pox  occurred  in  the  German  army  between  1874 
and  1882.1 

A  revaccination,  even  if  successful,  seldom  passes  through 
all  the  typical  stages  of  a  primary  vaccination.  The  vesicle 
rarely  becomes  so  full  and  plump,  and  is  more  frequently  flat 
and  irregular  in  outline.  Swelling  of  the  axillary  glands  and 
other  complications  also  seem  to  be  more  frequent  than  in  cases 
where  the  vaccination  is  done  for  the  first  time. 

The  question  whether  the  lymph  direct  from  the  cow  or 
humanized  lymph  is  the  more  efficient  has  caused  much  dis- 
cussion. The  objections  urged  against  the  use  of  humanized 
virus  are :  first,  that  its  protective  power  has  become  diminished 
by  transmission  through  many  generations ;  second,  that  it  is 
liable  to  transmit  other  diseases,  such  as  syphilis,  tuberculosis, 
scrofula,  etc. ;  third,  that  it  is  frequently  difficult  to  obtain  in 

1  Frolich,  Militar-Medicin,  p.  461. 


SMALL-POX.  343 

sufficient  quantities  in  an  emergency,  such  as  an  actual  or 
threatened  epidemic. 

The  first  objection  is  disproved  by  the  testimony  of  many 
of  the  most  distinguished  medical  men  in  Europe  and  this 
country.  Humanized  vaccine  virus,  when  properly  inoculated, 
seems  to  be  as  completely  protective  against  small-pox  as  that 
taken  direct  from  the  animal.  Among  its  advantages  are,  that 
it  "  takes  "  more  readily  and  runs  through  its  stages  of  develop- 
ment in  a  shorter  time,  and  that  it  will  retain  its  active  proper- 
ties for  a  greater  length  of  time  than  animal  virus.  The 
physician  can  usually  control  the  source  whence  he  obtains  it. 
He  can  watch  over  the  subject  that  furnishes  it  and  reject  that 
which  is  suspicious.  With  humanized  lymph  collected  by  the 
physician  himself  there  can  be  no  doubt  as  to  its  purity  or  age ; 
with  animal  lymph  furnished  by  the  cultivators  of  that  article 
there  can  be  no  certainty  about  either  of  these  important  points. 

That  syphilis  has  been  inoculated  with  humanized  virus 
can  no  longer  be  open  to  doubt.  The  recent  experiment  of 
Dr.  Cory,  of  England,  has  settled  this  question  definitely.  With 
care,  however,  this  sad  accident  can  easily  be  avoided,  and  the 
fact  that  syphilis  has  been  so  rarely  transmitted  by  vaccination 
is  sufficient  evidence  that  the  danger  of  such  infection  is  not 
very  great. 

The  most  serious  objection  against  the  exclusive  use  of 
humanized  lymph  is,  that  in  grave  emergencies,  such  as  a 
rapidly-spreading  epidemic  of  small-pox,  it  is  difficult  to  obtain 
a  sufficient  supply  of  the  lymph. 

Humanized  virus  is  inoculated,  either  in  the  fresh  state, 
i.e.,  the  lymph  is  taken  from  the  vesicle  on  the  seventh  day  and 
inoculated  directly  into  the  arms  of  other  individuals,  or  else  the 
vesicle  is  allowed  to  dry  into  a  crust,  with  which  a  thin  paste  is 
made  by  moistening  with  water  at  the  time  of  vaccination.  The 
readiest  way  of  using  the  crust  is  to  crush  a  small  fragment 
between  two  small  squares  of  glass,  then  moistening  it  with  a 
drop  of  warm  (not  hot)  water,  and  smearing  it  on  the  spot 


344  TEXT-BOOK    OF   HYGIENE. 

where  the  vaccination  is  to  be  made.  With  the  lancet  a 
number  of  cross-scarifications  are  then  made,  and  the  virus  well 
rubbed  in.  Only  so  much  of  the  crust  should  be  moistened  as 
will  be  used  at  the  time.  Particular  care  must  be  taken  not  to 
use  saliva  for  moistening  the  crust.  Aside  from  being  unclean, 
there  is  danger  of  producing  blood-poisoning  by  inoculating 
certain  of  the  oral  secretions.1 

Animal  virus  is  obtained  by  inoculating  a  calf  or  heifer 
with  virus,  either  derived  from  a  case  of  small-pox,  from  another 
case  of  cow-pox,  or  by  re-inoculating  humanized  vaccine  virus 
into  the  animal.  The  vesicles  are  opened  on  the  seventh  day, 
and  ivory  points  or  the  ends  of  quills  coated  with  the  lymph 
and  dried  with  a  gentle  heat. 

In  vaccinating  with  animal  virus,  the  quill  or  ivory  point 
is  first  moistened  with  a  drop  of  water  to  soften  the  adhering 
lymph ;  the  scarification  or  abrasion  of  the  skin  is  then  made 
with  the  lancet,  and  the  virus  rubbed  well  into  the  scarified 
spot. 

In  using  animal  virus  the  successive  stages  of  development 
are  usually  one  or  two  days  later  than  when  humanized  virus 
is  used.  In  the  former  case  the  areola  is  rarely  developed 
before  the  ninth  day. 

Certain  complications  are  likely  to  occur  in  the  course  of 
the  vaccinia,  of  which  the  student  should  be  aware. 

When  the  areola  appears  there  is  usually  more  or  less 
fever.  Sometimes  the  constitutional  manifestations  are  de- 
cidedly marked,  fever  of  a  high  grade  being  not  uncommon. 
In  addition  to  the  glandular  enlargement  arid  tenderness,  an 
outbreak  of  roseola  sometimes  comes  on  about  the  ninth  or 
tenth  day.  This  eruption  may  be  mistaken  for  scarlet  fever, 
but  if  it  is  remembered  that  two  infectious  diseases  rarely  co- 
exist in  one  individual  during  their  full  development  this  error 
will  be  avoided. 

Erysipelas  involving  the  entire  arm  is  sometimes  observed 

1  See  Stern  berg  and  Magnin,  Bacteria,  p.  355.    Second  edition. 


SMALL-POX.  345 

as  a  complication  of  vaccination.  This,  in  nearly  every  case, 
depends  upon  some  depravement  of  the  patient's  constitution, 
innutrition,  bad  sanitary  surroundings,  or,  perhaps,  more  fre- 
quently, chronic  alcoholism.  Individuals  who  are  habitually 
intemperate  in  the  indulgence  of  alcoholic  liquors  are  espe- 
cially unfavorable  subjects  for  vaccination.  The  results  are, 
fortunately,  rarely  serious  to  the  patient. 

Another  inconvenient  complication  of  vaccination  is  the 
formation  of  a  deep,  ill-looking,  sloughing  ulcer  at  the  vacci- 
nated point.  This  has  been,  in  the  author's  experience,  a  much 
more  frequent  concomitant  when  animal  virus  has  been  used  than 
when  humanized  virus  was  resorted  to.  It  should  be  borne  in 
mind  that  a  very  sore  arm,  especially  if  followed  by  the  formation 
of  an  ulcer  or  gangrenous  sore,  may  not  be  protective  against 
small-pox.  Such  a  patient  should  not  be  considered  properly 
vaccinated,  and  must  be  revaccinated  as  soon  as  he  recovers,  or 
immediately  if  there  is  any  danger  of  small-pox  infection. 

Children  with  eczematous  eruptions,  however,  localized 
upon  any  portion  of  the  body,  should  not  be  vaccinated  until 
the  eruption  is  first  cured,  except  in  times  of  danger  from 
small-pox.  The  eczema  will  be  almost  certainly  rendered  worse 
in  consequence  of  the  general  hyperaemia  accompanying  the 
febrile  reaction,  and  the  physician  who  performs  the  vaccination 
will  be  blamed  for  causing  the  skin  disease. 

The  author  has  placed  on  record1  two  cases  of  general 
psoriasis  following  vaccination,  and  other  cases  have  been  since 
reported.  Urticaria  and  exudative  erythema  have  also  been 
repeatedly  observed. 

As  before  stated,  syphilis  may  be  communicated  to  the 
vaccinee  by  vaccine  virus  obtained  from  a  syphilitic  subject,  but 
this  accident  is  infrequent.  There  can  be  little  doubt  that  some 
of  the  cases  reported  as  "  vaccinal  syphilis  "  are  cases  of  tardy 
hereditary  syphilis,  lighted  up  by  the  general  systemic  disturb- 
ance following  vaccination. 

1  Journal  Cutaneous  and  Venous  Diseases,  vol.  i,  No.  1,  p.  11. 


346  TEXT-BOOK   OF   HYGIENE. 

Next  in  importance  to  vaccination  in  the  prophylaxis  of 
small-pox  is  prompt  isolation  of  the  sick.  No  one  but  the 
medical  and  other  attendants  of  the  sick  should  he  allowed  to 
come  in  contact  with  them.  All  attendants  and  other  persons 
exposed  to  the  infection  should,  of  course,  be  promptly  vacci- 
nated, unless  this  has  been  successfully  done  within  the  previous 
year  or  two.  Disinfection  of  all  discharges  from  the  patient  and 
of  the  room  and  its  contents,  after  the  patient  has  recovered  or 
died,  must  be  practiced.  The  best  disinfectants  in  small-pox  are 
bichloride  of  mercury,  free  chlorine,  and  sulphurous  acid. 

When  it  is  learned  that  a  person  has  small-pox,  if  he  is  not 
removed  to  a  special  hospital,  a  room  should  be  prepared  for  his 
occupancy.  The  carpets  should  be  taken  up  and  the  floor  kept 
clean.  Window-curtains  and  unnecessary  furniture  and  drapery 
should  be  removed  from  the  room.  After  recovery  of  the 
patient  the  bed-clothing  must  be  thoroughly  disinfected  with 
steam  or  sulphurous  acid,  or  destroyed  by  fire.  The  individual 
himself  should  not  be  allowed  to  mingle  with  healthy  persons 
until  all  danger  of  infection  is  passed  and  the  surface  of  his 
body  has  been  thoroughly  disinfected! 

At  a  recent  conference  of  sanitary  officials  in  the  city  of 
Chicago  (May,  1894)  the  following  propositions  were  adopted. 
They  represent  the  most  advanced  conclusions  of  competent 
authority  upon  the  most  practical  means  of  limiting  the  spread 
of  small-pox : — 

"  1.  The  city  should  be  divided  into  districts  containing 
not  more  than  10,000  people. 

"  2.  Each  district  should  be  placed  under  the  supervision 
of  a  competent  medical  inspector  with  necessary  assistants  to 
(a)  make  a  house-to-house  inspection  ;  (ft)  to  successfully  vacci- 
nate, within  the  shortest  possible  time,  all  persons  who  have  not 
been  vaccinated  during  the  outbreak,  and  that  the  first  vaccina- 
tion be  within  seven  days ;  (c)  to  properly  disinfect  all  houses 
and  their  contents  where  small-pox  occurs. 

"  3.  Necessary  means  and  appliances  for  efficient  disirifec- 


ASIATIC   CHOLERA.  347 

tion  of  materials,  premises,  etc.,  should  be  provided  as  the 
exigencies  of  each  district  may  require. 

"  4.  Each  case  of  small-pox  should  be  immediately  removed 
to  a  suitably  constructed  and  properly  equipped  and  officered 
isolation  hospital. 

"  5.  Except  in  extreme  cold  weather,  hospital  tents,  as 
prescribed  in  the  United  States  Army  Regulations,  floored  and 
warmed,  are  preferable  to  the  average  hospital  or  private  dwell- 
ing, and  increase  the  chances  of  recovery  of  the  patients.  Cases 
of  small-pox  necessarily  detained  in  their  own  homes  should,  with 
their  attendants,  be  rigidly  isolated  during  the  period  of  danger, 
and  physicians  visiting  such  patients  professionally  shall  be  sub- 
ject to  such  regulations  as  may  be  prescribed  by  the  local  health 
officer. 

"  6.  Persons  exposed  to  small-pox  contagion  should  be 
immediately  vaccinated  or  revaccinated,  and  kept  under  observa- 
tion for  not  less  than  fourteen  days  from  time  of  last  exposure. 

"•  7.  It  is  the  sense  of  this  conference  that  where  such 
measures  are  all  enforced  it  will  not  be  necessary  for  neighbor- 
ing cities  and  states  to  exclude  all  persons  who  come  from  such 
city  who  are  not  protected  against  small-pox  by  vaccination,  and 
to  require  disinfection  of  all  baggage  and  merchandise  capable 
of  conveying  small-pox  infection." 

ASIATIC    CHOLERA. 

A  disease  which  causes  the  death  of  three-fourths  of  a 
million  of  human  beings  where  it  is  endemic  within  the  space 
of  five  years,  and  which  makes  periodical  excursions,  spreading 
over  nearly  the  entire  inhabited  globe  with  destructive  violence, 
must  surely  command  the  interested  attention  of  every  intelli- 
gent person.  Asiatic  cholera  is  endemic  in  India,  where  it 
probably  originated  centuries  ago.  Some  authors  claim  to  have 
found  satisfactory  evidence  of  its  existence  in  the  writings  of  the 
classical  authors  of  India  and  Greece  at  a  period  as  early  as  the 
second  century  of  the  Christian  era.  The  evidence  is,  however, 
not  beyond  question.  In  the  sixteenth  and  seventeenth  cen- 


348  TEXT-BOOK   OF   HYGIENE. 

turies  European  travelers  in  the  East  gave  pretty  exact  accounts 
of  the  disease.  One  of  the  most  definite  of  these  was  given  by 
Gaspar  Correa,  an  officer  in  Vasco  da  Gama's  expedition  to 
Calicut.  He  states  that  Zamorin,  the  chief  of  Calicut,  lost 
20,000  of  his  troops  by  the  disease.  A  still  more  definite  and 
the  first  trustworthy  account  is  that  of  Sonnerat,  a  French  trav- 
eler. He  describes  a  pestilence  having  all  the  characters  now 
recognized  as  belonging  to  Asiatic  cholera,  which  prevailed  in 
the  neighborhood  of  Pondicherry  and  the  Coromandel  coast  in 
1768  and  1769,  and  which  carried  off  60,000  of  those  attacked 
by  it  within  a  year.  Dr.  Macpherson,  in  his  "  History  of  Cholera," 
gives  numerous  references  which  indisputably  establish  the  en- 
demic existence  of  the  disease  in  India  anterior  to  the  present 
century. 

Being  endemically  prevalent  over  a  greater  or  less  area  of 
India  for  many  years,  cholera  finally,  in  1817,  crossed  the 
boundaries  of  that  country,  and,  advancing  in  a  southeasterly 
direction,  invaded  Ceylon  and  the  Sunda  Islands  in  1818.  In  a 
westerly  direction  the  disease  was  carried  to  the  islands  of 
Mauritius  and  Reunion,  and  reached  the  African  coast  in  1820. 
During*  this  year  it  also  traveled  northeasterly,  devastating  the 
Chinese  Empire  for  the  two  following  years,  reaching  Nagasaki, 
in  Japan,  in  1822. 

In  1821  the  disease  spread  from  India  in  a  westerly  direc- 
tion, extending  along  the  east  coast  of  Arabia  to  the  border  of 
Mesopotamia  and  Persia.  In  the  spring  of  1822  it  began  with 
renewed  violence,  following  the  river  Tigris  to  Kurdistan,  and, 
extending  farther  in  a  westerly  direction,  reached  the  Mediter- 
ranean coast  of  Syria.  In  the  following  year,  1823,  it  extended 
from  Persia  into  Asiatic  Russia,  reaching  Astrachan  on  the 
European  border  in  September,  but  dying  out  nearly  every- 
where beyond  the  borders  of  India  during  the  ensuing  winter. 

In  1826  cholera  again  advanced  from  India,  reaching 
Orenburg  in  Russia  in  1829,  and  in  the  following  winter 
appeared  in  St.  Petersburg.  Extending  to  the  north  and  south, 


ASIATIC   CHOLERA.  349 

it  invaded  Finland  and  Poland  the  same  year.  From  Persia  the 
disease  spread*  to  Egypt  and  Palestine  in  1830—31. 

From  Russia  the  pestilence  invaded  Germany  in  1831, 
passing  thence  in  1832  into  France,  the  British  Isles,  Belgium, 
the  Netherlands,  Norway,  and  Sweden.  In  the  latter  year 
cholera  crossed  the  Atlantic  Ocean  for  the  first  time,  being  car- 
ried to  Canada  by  emigrants  from  Ireland,  and  spreading  thence 
to  the  United  States  by  way  of  Detroit.  In  the  same  year  it 
was  imported  into  New  York  by  emigrants,  and  rapidly  spread 
along  the  Atlantic  coast.  During  the  winter  of  1832  it  appeared 
at  New  Orleans,  and  passed  thence  up  the  Mississippi  Valley. 
Extending  into  the  Indian  country,  causing  sad  havoc  among 
the  aborigines,  it  advanced  westward  until  its  further  progress 
was  stayed  by  the  shores  of  the  Pacific  Ocean.  In  1834  it 
re-appeared  on  the  east  coast  of  the  United  States,  but  did  not 
gain  much  headway,  and  in  the  following  year  New  Orleans  was 
again  invaded  by  way  of  Cuba.  It  was  imported  into  Mexico  in 
1833.  In  1835  it  appeared  for  the  first  time  in  South  America, 
being  restricted,  however,  to  a  mild  epidemic  on  the  Guiana  coast. 

While  the  pestilence  was  advancing  in  the  Western  Hemi- 
sphere, it  also  spread  throughout  Southern  Europe,  invading,  in 
turn,  Portugal,  Spain,  and  Italy. 

Extending  in  an  easterly  direction  from  India,  the  disease 
reached  China  and  Japan  in  1830-31 ;  westwardly,  Africa 
was  invaded  in  1834,  and  ravaged  by  the  epidemic  during  the 
following  three  years. 

This  second  extensive  outbreak  of  cholera  ended  in  1837, 
disappearing  at  all  points  beyond  the  borders  of  India.  In 
1846  the  disease  again  advanced  beyond  its  natural  confines, 
reaching  Europe,  by  way  of  Turkey,  in  1848.  In  the  autumn 
of  this  year  it  also  appeared  in  Great  Britain,  Belgium,  the 
Netherlands,  Sweden,  and  the  United  States,  entering  by  way  of 
New  York  and  New  Orleans.  In  the  succeeding  two  years  the 
entire  extent  of  country  east  of  the  Rocky  Mountains  was  in- 
vaded. During  1851  and  1852  the  disease  was  frequently  im- 


350  TEXT-BOOK   OF   HYGIENE. 

ported  by  emigrants,  who  were  annually  arriving  in  great  num- 
bers from  the  various  infected  countries  of  Europe.  In  1853 
and  1854,  cholera  again  prevailed  extensively  in  this  country, 
being,  however,  traceable  to  renewed  importation  of  infected 
material  from  abroad.  In  the  following  two  years  it  also  broke 
out  in  numerous  South  American  States,  where  it  prevailed  at 
intervals  until  1863. 

Hardly  had  this  third  great  pandemic  come  to  an  end 
before  the  disease  again  advanced  from  the  Ganges,  spreading 
throughout  India,  and  extending  to  China,  Japan,  and  the  East 
India  Archipelago  during  the  years  1863  to  1865.  In  the  latter 
year  it  reached  Europe  by  way  of  Malta  and  Marseilles.  It 
rapidly  spread  over  the  Continent,  and  in  1866  was  imported  into 
this  country  by  way  of  Halifax,  New  York,  and  New  Orleans. 
This  epidemic  prevailed  extensively  in  the  Western  States,  but 
produced  only  slight  ravages  on  the  Atlantic  coast,  being  kept 
in  check  by  appropriate  sanitary  measures.  In  the  same  year 
(1866)  the  disease  was  also  carried  to  South  America,  and  in- 
vaded, for  the  first  time,  the  States  bordering  on  the  Rio  de  la 
Plata  and  the  Pacific  coast  of  the  Continent. 

While  the  epidemic  was  thus  advancing  westward  from  its 
home  in  India,  it  was  at  the  same  time  spreading  northwardly 
over  the  entire  western  part  of  Asia,  and  in  a  southeasterly 
direction  over  Northern  Africa.  In  the  latter  continent  it  pre- 
vailed from  1865  to  1869. 

Cholera  never  entirely  disappeared  in  Russia  during  the 
latter  half  of  the  sixth  decade,  and  in  1870  it  again  broke  out 
with  violence,  carrying  off  a  quarter  of  a  million  of  the  inhabi- 
tants before  dying  out  in  1873.  It  spread  from  Russia  into 
Germany  and  France,  and  was  imported,  in  1873,  into  this 
country,  entering  by  way  of  New  Orleans  and  extending  up 
the  Mississippi  Valley.  None  of  the  Atlantic-coast  cities  suf- 
fered from  the  epidemic  in  1873,  and  since  that  year  the  United 
States  have  been  entirely  free  from  the  disease,  with  the  excep- 
tion of  a  few  imported  cases  in  New  York  Harbor  in  1887. 


ASIATIC   CHOLERA.  351 

In  June,  1883,  a  new  epidemic  of  cholera  broke  out  in 
Egypt,  where  it  raged  with  great  violence.  The  disease  first 
appeared  in  Damietta,  near  the  outlet  of  the  Suez  Canal.  It 
was  unquestionably  imported  from  India,  probably  Bombay, 
where  it  prevailed  as  early  as  the  month  of  May.  At  the  time 
of  the  outbreak  in  Damietta  that  city  was  overcrowded  with 
people  who  had  come  to  attend  a  great  religious  fair  and  festival. 
It  has  been  proven  that  pilgrims  from  Bombay  were  among  the 
attendants  at  this  fair.  The  epidemic  came  to  an  end  in  Egypt 
in  the  autumn  of  1883.  In  the  same  year  (1883)  a  small  out- 
break occurred  in  Marseilles,  but  intelligence  of  it  was  carefully 
suppressed  by  the  authorities.  The  disease  does  not  seem  to 
have  spread  from  this  centre,  but  in  June  of  the  following  year 
cholera  broke  out  in  Toulon,  having  probably  been  imported  in 
a  transport  ship  returning  from  Tonquin.  This  outbreak  was 
very  violent  and  rapidly  spread  throughout  Southern  France, 
Italy,  and  Spain.  After  apparently  dying  out  during  the  winter, 
it  re-appeared  in  the  spring  of  1885  with  renewed  violence.  The 
total  number  of  cases  in  Spain  alone  in  the  latter  year  was  over 
one-third  of  a  million,  with  nearly  120,000  deaths. 

In  the  summer  of  1885  cholera  also  broke  out  in  a  viru- 
lent form  in  Japan,  and,  after  a  cessation  during  the  following 
winter,  recurred  with  increased  fatality  in  1886.  In  the  latter 
year  there  were  over  100,000  deaths  from  the  disease  in  that 
country. 

During  1886  and  1887  cholera  continued  in  Southeastern 
Italy  and  in  the  Austrian  dominions  at  the  head  of  the  Adriatic. 
A  few  cases  occurred  in  France  and  Germany,  but  by  stringent 
sanitary  measures  an  epidemic  was  averted. 

In  November,  1886,  cholera  was  carried  to  South  America 
in  an  Italian  ship,  the  "  Perseo,"  bound  from  Genoa  to  Buenos 
Ayres.  The  disease  rapidly  spread  in  the  Argentine  Republic, 
and,  crossing  the  Andean  range,  invaded  the  Pacific  coast  of  the 
South  American  continent  for  the  second  time,  reaching  Chili 
and  Bolivia  and  threatening  Peru  and  Brazil.  In  Chili  alone 


352  TEXT-BOOK   OF   HYGIENE. 

there  were  over  10,000  deaths  in  the  first  six  months  of  1887. 
The  further  progress  of  the  epidemic  was  arrested  and  the  entire 
Western  Hemisphere  is  now  free  from  the  disease. 

.From  July  to  December,  1889,  cholera  prevailed  with  con- 
siderable virulence  in  Mesopotamia.  In  1890  it  re-appeared  in 
Spain;  in  1892  in  France  and  Germany,  raging  with  great  vio- 
lence in  Hamburg.  Nearly  8000  persons  died  from  the  disease 
in  the  latter  city.  Some  cases  were  brought  thence  to  New 
York  Harbor,  but  the  active  sanitary  measures  taken  were  suc- 
cessful in  preventing  its  further  spread.  At  the  present  writing 
(August,  1894),  the  disease  again  threatens  Europe. 

This  brief  historica.1  sketch  of  all  the  epidemics  of  cholera 
observed  beyond  the  borders  of  India  demonstrates  several  facts : 
first,  that  the  home  or  breeding-place  of  cholera  is  in  India, 
especially  the  delta  of  the  Ganges,  whence  it  spreads  at  intervals 
throughout  the  world ;  second,  that  it  always  advances  along  the 
lines  of  travel  of  large  bodies  of  human  beings  ;  and,  third,  that 
it  advances,  by  preference,  along  water-routes.  Exceptions  un- 
doubtedly occur,  but  the  rule  is  a  general  one.  The  disease 
seems  to  spread  with  difficulty  along  the  lines  of  railroad.  When 
the  disease  has  extended  from  New  Orleans  it  has  always  been 
up  the  Mississippi  Valley,  expending  its  violence  upon  the  river 
cities — Vicksburg,  Memphis,  St.  Louis,  and  Cincinnati. 

Several  factors  must  concur  before  there  can  be  an  epidemic 
of  cholera.  These  are :  first,  the  cholera  poison ;  second,  cer- 
tain local  conditions  of  air,  soil,  or  water ;  and,  third,  individual 
predisposition.  Without  a  concurrence  of  all  these  conditions 
no  outbreak  can  occur.  If,  by  any  means,  the  co-existence  of 
these  three  conditions  can  be  prevented,  cholera  can  be  averted. 
The  following  are  facts  bearing  upon  this  question :  Cholera  is 
communicated  through  the  agency  of  a  specific  poison.  This 
does  not  admit  of  doubt.  The  poison  may  be  either  an  organic 
germ,  or  of  an  inorganic,  particulate,  or  gaseous  nature.  The 
recent  researches  of  Dr.  Robert  Koch,  of  Germany,  indicate 
that  a  micro-organism  found  in  the  intestinal  discharges  of  cholera 
patients  and  in  the  bodies  of  those  dead  with  the  disease  is  the 


ASIATIC   CHOLERA.  353 

active  agent  in  propagating  the  malady.  This  organism,  named 
by  Koch  the  "comma  bacillus,"  from  its  general  resemblance 
to  a  comma,  was  first  discovered  by  this  eminent  pathologist  in 
the  intestinal  contents  of  cholera  corpses  in  Egypt  in  1883,  and 
in  the  following  year  more  thoroughly  studied  in  Calcutta, 
whither  he  had  been  sent  by  the  German  government  to  pursue 
his  investigations.  It  has  been  demonstrated  that  this  germ  is 
always  present  in  the  discharges  of  cholera  patients,  and  up  to 
this  time  it  has  not  been  found  in  any  other  disease.  Experi- 
ments upon  animals  have  also  shown  that  cholera  can  be  pro- 
duced in  the  latter  by  introducing  the  germ  into  their  bodies  in 
various  ways.  The  demonstration  of  the  bacterial  nature  of 
cholera  seems  to  be  complete. 

While  cholera  cannot  be  regarded  as  personally  contagious 
in  the  same  sense  or  in  the  same  degree  as  small-pox,  there  can 
be  no  doubt  that  it  is  spread  only  by  the  poison  from  other  cases 
of  the  disease.  The  regularity  of  its  march  along  routes  by 
which  the  intercourse  of  human  beings  takes  place,  and  always 
in  connection  with  other  cases  of  cholera,  proves  this.  There  is 
no  undoubted  case  on  record  where  genuine  cholera  has  been 
spontaneously  developed  outside  of  India. 

That  certain  local  geological^  and  perhaps  meteorological 
conditions  are  necessary  for  the  propagation  or  virulence  of  the 
poison  of  cholera  is  beyond  dispute.  Outbreaks  usually  take 
place  during  the  summer  or  autumn,  and  nearly  always  partly 
or  entirely  die  out  during  cold  weather.  Further,  in  nearly  all 
epidemics,  certain  cities  or  towns,  or  portions  of  a  town,  into 
which  persons  sick  with  cholera  are  brought,  and  where  the 
poison  of  the  disease  is  thus  imported,  remain  exempt  from  the 
effects  of  the  epidemic.  The  inference  to  be  drawn  from  this 
fact  is  that  in  such  localities  the  local  conditions  are  unfavorable 
to  the  development  of  the  poisonous  germ,  and  it  becomes  inert. 

In  India  all  the  local  conditions  favorable  to  the  propagation 
of  the  cholera-germ  are  found.  The  filthy  personal  habits  of 
the  people,  the  overcrowding,  the  intense  heat,  the  lack  of  suf- 

23 


354  TEXT-BOOK   OF   HYGIENE. 

ficient,  appropriate,  or  properly-prepared  food,  and  the  exten- 
sive pollution  of  the  water-supply,  all  combine  to  produce  the 
necessary  conditions  of  development  of  the  cause  of  cholera. 
These  conditions,  doubtless,  to  a  considerable  extent,  give  rise 
to  that  depression  of  the  system  which  seems  necessary  to  con- 
stitute the  individual  predisposition  to  become  infected. 

Given,  then,  at  any  place,  a  number  of  persons  of  a  lowered 
degree  of  vitality, — that  is  to  say,  persons  not  capable  of  resisting 
unfavorable  influences  upon  their  health  under  unfavoring  con- 
ditions ;  given  conditions  of  climate,  water,  and  soil  more  or  less 
similar  to  those  existing  in  India :  only  the  introduction  of  the 
third  factor,  the  cholera  poison,  is  needed  to  cause  an  outbreak. 
In  many  cities  of  this  country  and  Europe,  as  proven  by  the 
most  recent  epidemics  in  Toulon,  Marseilles,  Naples,  and  other 
cities  of  Italy  and  Spain,  the  conditions  are  present  which  would 
furnish  the  most  favorable  breeding-place  for  the  cholera-germ 
if  introduced. 

The  dejections  and  vomited  matters  of  cholera  patients  con- 
tain the  active  agent  which  produces  the  disease.  The  contagi- 
ous principle  contained  in  these  excretions,  probably  the  cholera- 
germ  or  "comma  bacillus"  discovered  by  Koch,  may  gain  an 
entrance  into  the  body  through  the  drinking-water  or  through 
infected  air.  Probably  both  modes  are  equally  competent  chan- 
nels of  infection.  The  prevailing  theory  is  that  pollution  of  the 
drinking-water  is  the  most  frequent  source  of  the  rapid  spread 
of  the  disease.  A  very  striking  instance  of  this  occurred  in 
London  during  the  epidemic  of  1854,  which  has  already  been 
referred  to.1 

Another  striking  instance  of  the  communication  of  cholera 
by  polluted  water  has  been  reported  by  Mr.  John  Simon,  long  the 
chief  medical  officer  of  the  English  "Local  Government  Board." 
The  facts  are  as  follow :  The  Lambeth  Water  Company  drew 
its  supply  from  the  Thames,  at  Ditton,  above  the  influence  of 
the  London  sewage  and  the  tidal  flux.  The  South wark  and 

1  See  ante,  page  64. 


ASIATIC   CHOLERA.  355 

Vauxhall  Company  drew  its  supply  from  the  river  near  Vauxhall 
and  Chelsea.  The  water  of  the  Lambeth  Company  was  toler- 
ably pure,  and  that  of  the  Southwark  and  Vauxhall  Company 
was  very  impure.  The  water  of  both  companies  was  distributed 
in  the  same  district  at  the  same  time  and  among  the  same  class 
of  people,  the  pipes  of  the  two  companies  being  laid  pretty 
evenly  in  the  same  areas,  in  many  places  running  side  by  side 
in  the  same  streets,  and  the  houses  supplied  being  pretty  equally 
distributed.  The  deaths  from  cholera  in  the  houses  supplied  by 
the  Lambeth  Company  were  at  the  rate  of  37,  and  in  the  houses 
supplied  by  the  Southwark  and  Vauxhall  Company  at  the  rate 
of  130,  to  every  10,000  persons  living.  It  appears,  therefore, 
that  of  the  drinkers  of  the  foul  water  about  three  and  a  half 
times  as  many  as  those  who  drank  the  pure  water  died  of  cholera. 

But  the  spread  of  cholera  cannot  always  be  referred  to  pol- 
lution of  the  drinking-water.  In  many  epidemics  no  relation 
can  be  shown  to  exist  between  the  spread  of  the  disease  and  im- 
pure water.  Professor  von  Pettenkofer,  of  Munich,  has  shown, 
by  a  number  of  carefully-conducted  observations,  that  the  prop- 
agation of  cholera  often  bears  a  very  direct  relation  to  changes 
in  the  stage  of  the  subsoil-  or  ground-  water.  This  does  not 
mean  that  the  subsoil-water  is  directly  or  necessarily  the  agent 
for  the  spread  of  the  disease,  but  that  its  stage,  or  variability, — 
now  high,  now  low, — may  be  considered  as  an  index  of  certain 
processes  going  on  in  the  soil  which  are  intimately  connected 
with  the  propagation  of  cholera  as  well  as  of  certain  other  in- 
fectious diseases,  chief  among  which  is  typhoid  fever.  The 
relations  between  the  ground-water  level  and  cholera  outbreaks 
in  India  and  various  cities  in  Europe  and  America  give  strong 
support  to  the  views  of  von  Pettenkofer.1  The  relation  of  the 
ground-water  oscillations  to  pollution  of  water  in  wells,  when 
thoroughly  worked  out  will  probably  explain  discrepancies  which 
at  present  apparently  exist. 

In  addition  to  the  influence  of  the  ground-water  oscillations 
and  polluted  drinking-water  in  spreading  the  cholera-poison, 

1  See  page  140. 


356  TEXT-BOOK    OF   HYGIENE. 

must  be  mentioned  articles  of  food  contaminated  with  the  in- 
fectious matter  of  the  disease.  It  is  also  no  longer  open  to 
question  that  persons  may  become  infected  by  handling  the 
clothing  and  bedding  of  cholera  patients.  Laundresses  are  in 
special  danger  from  this  source. 

The  prophylaxis  against  cholera  comprises  such  measures 
as  will  prevent  the  admission  of  the  cholera-poison  into  a  com- 
munity, arrest  the  development  of  the  poison  after  its  introduc- 
tion, and  reduce  the  individual  susceptibility  to  attack. 

It  is  evident  from  the  foregoing  that  if  the  introduction  of 
the  cholera-poison  could  be  prevented  no  outbreak  of  the  dis- 
ease could  occur.  With  this  in  view,  some  have  urged  the  en- 
forcement of  a  strict  policy  of  non-intercourse  with  infected 
localities.  But  at  the  present  day  few  sanitarians  advocate  these 
extreme  measures.  A  modified  system  of  restricted  intercourse 
is  supported  by  many  authorities,  who  claim  that  by  the  adoption 
of  a  thorough  system  of  maritime  inspection,  disinfection,  and 
observation — a  rational  quarantine,  in  fact — the  poison  can  be 
rendered  ineffective  or  its  entrace  into  a  commmunity  prevented. 

The  best  authorities,  however,  think  that  it  is  not  only 
easier,  but  far  more  effective  to  place  the  threatened  locality  in 
such  a  sanitary  condition  that  the  development  of  the  cholera- 
poison  cannot  take  place.  The  contrast  between  the  effective- 
ness of  quarantine  and  local  sanitation  as  safeguards  against 
cholera  has  been  well  expressed  by  von  Pettenkofer,  who  com- 
pares cholera  epidemics  to  powder  explosions.  The  virus  of 
cholera,  he  says,  is  the  spark  that  evades  the  strictest  quaran- 
tine ;  the  powder  is  the  ensemble  of  local  conditions  which  pre- 
dispose to  the  outbreak.  "  It  is  wiser,  therefore,  to  seek  out  and 
remove  the  powder  than  to  run  after  and  try  to  extinguish  each 
individual  spark  before  it  drops  upon  a  mass  of  powder,  and, 
igniting  it,  causes  an  explosion  which  blows  us  into  the  air  with 
our  extinguishers  in  our  hands." 

The  measures  of  local  sanitation  to  be  enforced  are  such 
as  will  secure  cleanliness  of  person,  of  habitation  and  surround- 


ASIATIC    CHOLERA.  357 

ings,  of  air,  of  water,  and  of  soil.  Pollution  of  the  soil  should 
be  especially  guarded  against,  for  a  polluted  soil  means  impure 
air  arid  water,  and  these  mean,  if  not  an  infectious  disease, 
at  least  a  heightened  receptivity  to  its  influence.  The  quality 
of  the  drinking-water  used  must  be  above  suspicion  of  con- 
tamination by  the  poison.  Unless  the  latter  can  be  positively 
excluded  all  drinking-water  should  first  be  boiled.  It  may  then 
be  cooled  by  pure  ice.  Filtering  the  water  may  not  remove  the 
poison. 

The  individual  predisposition  to  cholera  is  best  guarded 
against  by  keeping  the  body  clean  and  well  nourished,  and  the 
mind  free  from  worry.  Underfeeding,  anxiety,  overwork,  ex- 
posure to  extremes  of  temperature,  intemperance  in  eating  and 
drinking  should  all  be  avoided,  as  they  tend  to  reduce  the  re- 
sistance of  the  system  to  the  influence  of  the  morbid  poison. 

Certain  measures  of  personal  prophylaxis  which  have 
proven  useful  heretofore  should  be  adopted  wherever  cholera 
prevails.  One  of  the  best  of  these  is  the  use  of  sulphuric-acid 
lemonade  as  a  drink.  Ten  to  15  drops  of  dilute  sulphuric  acid 
in  a  glass  of  water,  sweetened  with  sugar,  may  be  drunk  instead 
of  water.  Experience  with  it  during  the  epidemic  of  1866  has 
demonstrated  its  great  value  as  a  preventive  of  cholera.  The 
later  researches  of  Koch  have  also  shown  that  the  "comma 
bacillus,"  or  spirillum,  cannot  live  in  acid  solutions.  Hence, 
it  is  probable  that  if  the  contents  of  the  stomacli  were  always 
kept  acid  no  infection  could  occur  through  absorption  from  the 
stomach. 

A  painless  diarrhoea,  called  cholerine,  attacks  many  persons 
during  cholera  epidemics.  This  disorder  is  easily  curable  if 
promptly  attended  to,  but  if  allowed  to  run  on  it  may  develop 
into  a  malignant  attack  of  cholera. 

Among  the  means  of  securing  prompt  treatment  of  the 
poorer  classes  in  times  of  epidemics  is  the  establishment  of 
numerous  public  dispensaries,  where  medical  aid  can  always  be 
obtained.  The  establishment  of  such  dispensaries  and,  if 


358  TEXT-BOOK   OF   HYGIENE. 

possible,  of  temporary  hospitals  in  the  crowded  portions  of 
cities  is  a  very  important  part  of  the  prophylactic  treatment. 

Inasmuch  as  it  seems  definitely  established  that  the  dis- 
charges from  the  stomach  and  intestines  are  the  active  agents  in 
propagating  the  disease,  the  immediate  disinfection  of  such  dis- 
charges is  vitally  important.  The  stools  and  vomited  matters 
must  be  rendered  innocuous  by  germicidal  agents,  such  as  mer- 
curic chloride,  carbolic  acid,  or  chloride  of  lime. 

Clothing  and  bedding  should  be  disinfected  with  super- 
heated steam,  thorough  boiling,  or  fumigation  with  sulphur 
dioxide  or  chlorine.  Infected  articles  of  this  kind  should  not 
be  sent  to  a  laundry  until  they  have  been  thoroughly  disinfected 
by  one  of  the  above-mentioned  means. 

Apartments  which  have  been  occupied  by  cholera  patients 
should  be  thoroughly  fumigated,  before  being  re-occupied,  with 
burning  sulphur,  and  afterward  freely  exposed  to  the  air  by 
opening  doors  and  windows.  The  walls  may  also  be  washed 
with  a  solution  of  mercuric  chloride. 

The  most  efficient  disinfectant  is  mercuric  chloride  in  the 
proportion  of  1  part  in  2000  of  the  material  to  be  disinfected. 
The  readiest  way  of  securing  disinfection  with  this  agent  is  to 
add  a  solution  of  1  to  1000  to  an  equal  proportion  of  the  dis- 
charges to  be  rendered  innocuous.  The  mercuric  chloride  acts 
slowly,  and  hence  the  infected  material  should  be  exposed  to  the 
action  of  the  disinfecting  agent  for  at  least  two  hours  before  it 
can  safely  be  thrown  into  sewers  or  cess-pools. 

There  are  several  serious  objections  to  the  indiscriminate  use 
of  mercuric  chloride  by  the  public  as  a  disinfectant.  In  the 
first  place,  it  is  intensely  poisonous,  and  its  perfectly  transparent 
and  inodorous  solution  might  readily  be  accidentally  drunk  and 
cause  fatal  results.  To  reduce  this  danger,  the  Committee  on 
Disinfectants  of  the  American  Public  Health  Association  recom- 
mended the  addition  of  permanganate  of  potash  or  of  sulphate 
of  copper  (blue  vitriol)  to  color  the  solution.  Another  serious 
objection  to  mercuric  chloride  is  that  it  cannot  be  used  where 


ASIATIC    CHOLERA.  359 

the  disinfected  material  must  pass  through  lead  pipe,  as  this  is 
rapidly  corroded  by  the  sublimate.  In  many  water-closets  it  can 
therefore  not  be  used. 

Chloride  of  lime  (bleaching-powder)  has  been  found  to  be 
a  very  rapid  and  efficient  disinfectant,  as  well  as  a  deodorizer ; 
but  the  chlorine,  upon  which  its  effectiveness  depends,  is  often 
so  deficient  in  proportion,  and  the  compound  so  readily  deterio- 
rates that,  unless  a  preparation  can  be  obtained  that  contains  at 
least  25  per  cent,  of  available  chlorine,  it  may  prove  injurious 
by  causing  a  false  sense  of  security.  A  trustworthy  preparation 
may  be  dissolved  in  water,  when  required,  in  the  proportion  of 
1  to  100.  An  objection  to  its  use  is  the  pungent  odor  of  chlorine, 
which  is  very  offensive  to  many  persons. 

Dr.  Koch  recommends  carbolic  acid,  which  he  has  shown 
will  kill  the  "  comma  bacilli "  in  a  dilution  of  1  to  20  of  water. 
The  ordinary  preparations  of  carbolic  acid  sold  as  disinfectants 
are,  however,  not  to  be  relied  on,  many  of  them  not  containing 
more  than  2  per  cent,  of  the  acid.  Further  dilution  of  these 
agents  would  altogether  destroy  their  disinfecting  power.  The 
purer  article  is,  on  the  other  hand,  too  expensive  to  be  used  as 
a  disinfectant. 

Little's  soluble  phenyle  is  an  efficient  disinfectant  in-  the 
proportion  of  2  per  cent.  (1  to  50).  It  is  furnished  of  uniform 
strength,  is  moderately  cheap,  non-poisonous,  and  readily 
miscible  with  water.  In  addition  to  its  disinfecting  power,  it  is 
also  an  excellent  deodorizer,  promptly  removing  all  odors  of 
decomposition  and  putrefaction.  Its  only  objection  is  a  rather 
pungent  though  not  unpleasant  odor,  which  somewhat  resembles 
creasote. 

In  the  very  beginning  of  an  epidemic,  prompt  isolation  of 
the  sick  and  thorough  disinfection  of  the  surroundings  of  the 
patient  may  check  the  spread  of  the  disease.  Much  cannot  be 
expected  from  these  measures,  however,  unless  the  local  sanitary 
conditions  are  such  as  offer  a  hindrance  to  the  development  of  the 
cholera-poison.  It  is  plain,  therefore,  that  prophylactic  measures 


360  TEXT-BOOK   OF   HYGIENE. 

against  cholera,  to  be  effective,  must  be  brought  into  requisition 
before  the  epidemic  has  begun.  After  the  outbreak  of  the 
disease  it  may  be  too  late  to  put  the  threatened  locality  in  a 
good  sanitary  condition.  It  is  of  the  highest  importance  that 
preventive  measures  be  enforced  early.  Above  all,  the  purity 
of  the  drinking-water  must  be  safeguarded. 

RELAPSING   FEVER. 

Relapsing  fever  was  first  clearly  described  by  Dr.  John 
Rutty,  in  his  "  Chronological  History  of  the  Weather,  Seasons, 
and  Diseases  of  Dublin  from  1725  to  1765."  l  Near  the  end  of  the 
last  and  in  the  first  half  of  the  present  centuries  relapsing  fever 
was  frequently  met  with  in  an  epidemic  form  in  Ireland  and 
Scotland.  In  1847  the  disease  invaded  a  number  of  the  larger 

o 

cities  of  England.  From  1868  to  1873  it  prevailed  extensively 
in  England  and  Scotland.  On  the  continent  of  Europe  it  was 
first  observed  in  Russia  in  1833.  In  Germany  it  was  not 
recognized  as  a  distinct  disease  until  1847,  but  did  not  prevail 
epidemically  until  1868.  Since  then  it  has  often  been  observed 
in  that  country. 

Relapsing  fever  is  very  prevalent  in  India,  where  it  was 
first  observed  in  1856  by  Sutherland.  In  China  and  in  the 
countries  of  Africa  bordering  on  the  Red  Sea  the  disease  has 
been  recognized  by  observers. 

In  the  United  States  it  was  first  observed  among  emigrants 
in  Philadelphia  in  1844,  and  again  in  1869.  It  was  conveyed 
to  other  places,  but  has  never  prevailed  extensively  in  this 
country.  It  has  not  been  observed  in  the  United  States  since 
1871. 

The  predisposing  causes  of  relapsing  fever  are,  above  all, 
bad  sanitary  surroundings.  Want  and  overcrowding  seem  to  be 
much  less  important  factors  than  in  typhus  fever. 

Although  relapsing  fever  has,  since  it  was  first  clearly  dis- 
tinguished from  typhus  and  other  continued  fevers,  been  recog- 
nized as  an  eminently  contagious  and  infectious  disease,  it  was 

1  London,  1770. 


TYPHOID   FEVER.  361 

not  until  1873  that  its  immediate  cause  became  known.  In  that 
year  Obermeier  discovered  in  the  blood  of  patients  ill  with  this 
disease  a  minute,  spiral,  mobile  organism,  now  known  as  the 
spt'rillum  or  spirocJiCRte  Obermeieri. 

Obermeier  and  other  observers,  prominent  among  whom  is 
Dr.  Henry  V.  Carter,  have  demonstrated  the  constant  presence 
of  these  organisms  in  the  blood  during  the  attack.  Carter  and 
Koch  have  induced  the  disease  in  monkeys  by  inoculation  of  the 
parasite,  and  Moschutkowski  has  successfully  inoculated  it  in  the 
human  subject.  No  doubt  can  exist  at  the  present  day  that  the 
spirillum  of  Obermeier  is  the  true  cause  of  relapsing  fever. 

The  preventive  measures  consist  in  attention  to  details  of 
personal  hygiene ;  in  other  words,  local  sanitation,  disinfection 
of  infected  materials  (fomites).  and  complete  isolation  of  the  sick. 

TYPHOID   FEVER. 

The  first  accurate  clinical  accounts  of  typhoid  fever  date 
from  the  seventeenth  century,  when  Baglivi,  Willis,  Sydenham, 
and  others  described  cases  of  fever  which  in  their  clinical  char- 
acters correspond  to  the  disease  now  known  as  typhoid  fever. 
Strother,  however,  in  1729,  first  gave  a  description  of  the 
anatomical  characters  of  the  disease,  which  he  says  is  a  "  symp- 
tomatical  fever,  arising  from  an  inflammation,  or  an  ulcer,  fixed 
on  some  of  the  bowels."  Bretonneau  and  Louis,  in  France; 
Hildenbrand,  in  Germany ;  William  Jenner,  in  England ;  and 
Drs.  Gerhard  and  Pennock,  in  this  country,  clearly  pointed  out 
the  essential  distinction  between  typhoid  and  other  fevers,  during 
the  first  half  of  the  present  century. 

At  the  present  day  typhoid  fever  is  met  with  everywhere 
throughout  the  world.  It  is  at  nearly  all  times  a  constituent  of 
mortality  tables.  It  affects  by  preference  persons  between 
the  ages  of  15  and  30  years,  although  no  age  is  entirely 
exempt.  It  is  always  more  prevalent  in  the  autumn  and  winter. 

The  disease  is  probably  due  to  an  organic  poison,  which 
gains  entrance  into  the  body  through  the  respiratory  or  digestive 


362  TEXT-BOOK   OF    HYGIENE. 

tract.  Recent  observations  of  Eberth,  Gaffky,  and  others  seem 
to  indicate  that  the  morbific  agent  is  a  micro-organism  termed 
the  bacillus  typlioideus.  The  exact  relation  of  this  organism  to 
the  disease  has  not  been  clearly  worked  out.  It  is  found  in  the 
intestinal  canal,  and  especially  in  the  characteristic  intestinal 
lesions  of  this  fever.  The  infective  agent  is  probably  contained 
in  the  dejections  of  patients.  The  disease  is  not  immediately 
contagious,  like  typhus  fever. 

The  medium  through  which  the  poison  is  introduced  into 
the  body  may  be  drinking-water,  food,  milk,  or  other  articles 
containing  the  infective  agent.  Localized  epidemics  due  to 
infected  water  or  milk  have  been  frequently  reported.1 

The  typhoid  poison  is  supposed  to  be  developed  in  cess- 
pools, sewers,  and  soil  polluted  by  the  products  of  animal  decom- 
position. Whether  it  ever  originates  de  novo  in  such  places  is 
a  much-disputed  proposition.  At  present  the  evidence  is  in 
favor  of  the  view  that  cases  of  typhoid  fever  are  always  derived 
from  pre-existing  cases.  The  germ  may  develop  in  sewers  and 
be  carried  in  the  sewer-air  from  place  to  place ;  it  may  be  carried 
into  the  soil  from  cess-pools  receiving  typhoid  dejections,  and 
there,  undergoing  development,  may  ascend  through  houses 
with  the  ground-air,  or  may  drain  into  wells  and  pollute  the 
drinking-water.  By  the  admixture  of  such  water  with  milk  or 
other  food  the  disease  may  be  propagated.  It  is  also  believed 
that  the  effluvia  from  typhoid  discharges  may  be  absorbed  by 
water  or  milk,  and  thus  infect  these  articles. 

The  prophylactic  measures  against  typhoid  fever  comprise 
isolation  of  the  sick,  prompt  disinfection  of  the  discharges,  and 
cleanliness  in  the  widest  sense.  The  water-  and  food-  supplies 
must  be  carefully  guarded  against  contamination  with  the  poison, 
and  all  decomposing  animal  matter  and  excreta  must  be  removed 
from  the  immediate  vicinity  of  dwellings.  The  requisites  for 
prevention  may  be  summed  up  as  pure  air,  pure  water,  uncon- 
taminated  food,  and  a  clean  soil. 

1  See  ante,  pp.  61-6L 


TYPHUS    FEVER.  363 

TYPHUS   FEVER. 

Wide-spread  pestilences  are  nearly  always  accompaniments 
of  famine  and  war.  Of  all  pestilential  diseases,  none  is  so  regu- 
lar in  its  coincidence  with  these  conditions  as  typhus  fever.  The 
earliest  accounts  which  unquestionably  refer  to  this  disease  date 
from  the  eleventh  century,  when  it  was  observed  at  a  number  of 
places  in  Italy.  In  the  succeeding  centuries  isolated  accounts 
of  it  appeared  in  the  chronicles  of  the  times,  but  no  scientific 
description  of  it  appeared  until  the  sixteenth  century.  During 
the  seventeenth,  eighteenth,  and  the  early  part  of  the  nineteenth 
centuries  it  prevailed  extensively  throughout  Europe.  The 
constant  wars  and  consequent  disturbances  of  the  social  rela- 
tions of  the  people,  famines,  overcrowding,  filth,  excesses  of  all 
kinds,  contributed  largely  to  the  development  and  spread  of 
typhus  fever.  For  a  number  of  years  past  no  extensive  epi- 
demic of  the  disease  has  been  observed,  although  both  in  this 
country  and  in  Europe  localized  outbreaks  are  frequently  met 
with. 

Typhus  fever  is  somewhat  more  prevalent  in  the  winter  and 
early  spring  months  than  during  the  rest  of  the  year,  but  not 
very  markedly  so. 

At  present,  typhus  fever  is  nearly  always  limited  to  times 
and  places  where  the  conditions  favoring  its  development  exist. 
Wherever  overcrowding,  in  connection  with  filth,  insufficient 
food,  and  bad  habits  are  present,  typhus  fever  is  likely  to  be  a 
visitor.  Thus,  in  overcrowded  and  ill- ventilated  emigrant  ships, 
in  jails  and  work-houses,  and  in  camps,  especially  when  stress 
of  weather  compels  the  crowding  together  of  soldiers  in  close 
huts  or  barracks,  the  disease  frequently  breaks  out. 

When  typhus  fever  appears  in  a  community,  those  classes 
of  the  people  who  are  subjected  to  the  conditions  just  mentioned 
are  almost  exclusively  attacked.  In  cities,  the  dwellers  in 
crowded  tenements,  or  in  courts  and  alleys,  suffer  most  severely — 
are,  in  fact,  almost  the  only  ones  attacked.  An  exception  must, 
however,  be  made  in  the  case  of  hospital  physicians  and  attend- 


364  TEXT-BOOK   OF    HYGIENE. 

ants  where  typhus-fever  patients  are  treated.  The  mortality 
among  these  is  always  large. 

Typhus  fever  is  contagious  and  infectious.  An  exposure 
for  a  length  of  time  to  an  atmosphere  impregnated  with  the 
poison  may  suffice  to  induce  an  attack.  The  poison  may  also 
be  conveyed  from  place  to  place  in  fomites.  Physicians  may 
carry  it  in  their  clothing,  if  they  have  been  exposed  to  a  typhus 
atmosphere. 

The  prevention  of  typhus  fever  consists  in  the  institution  of 
such  measures  as  will  secure  pure  air,  pure  water,  a  clean  soil 
and  dwellings,  and  cleanliness  of  body  and  clothing.  When  an 
outbreak  occurs,  the  sick  should  be  promptly  isolated,  the  well 
persons  removed  from  the  building  in  which  the  cases  have 
occurred,  and  efficient  measures  of  disinfection  carried  out.  The 
sick  should  be  treated  in  the  open  air  as  much  as  possible. 

YELLOW   FEYER. 

The  West  India  Islands,  the  Gulf  coast  of  Mexico,  the 
northern  part  of  the  Atlantic  coast  of  South  America,  and  a 
limited  section  of  the  west  coast  of  Africa  constitute  the  present 
home  of  yellow  fever.  From  this  area  (the  so-called  "  yellow- 
fever  zone  ")  the  disease  is  frequently  transported  to  contiguous 
or  distant  countries.  The  South  Atlantic  and  Gulf  coasts  of  the 
United  States  and  the  shores  of  the  Caribbean  Sea  are  most 
liable  to  the  epidemic  visitation  of  this  pestilence. 

The  first  trustworthy  account  of  an  epidemic  of  yellow 
fever  dates  from  the  year  1635,  when  it  prevailed  on  the  Island 
of  Guadeloupe.  This  and  the  adjoining  islands  of  Dominica, 
Martinique,  and  Barbadoes  were  invaded  a  number  of  times  in 
the  fifty  years  following  the  above  date.  Jamaica  was  invaded 
in  1655  and  Domingo  the  year  after.  In  1693  the  first  appear- 
ance of  the  disease  is  mentioned  in  the  United  States,  being 
observed  in  Boston,  Philadelphia,  and  Charleston.  In  1699  it 
appeared  as  an  epidemic  in  Vera  Cruz,  and  re-appeared  in  Phila- 
delphia and  Charleston.  Since  the  year  1700,  the  disease  has 


YELLOW  FEYER.  365 

appeared  in  an  epidemic  form,  at  one  or  more  places  within  the 
present  limits  of  the  United  States,  eighty  times,  the  last  consid- 
erable invasion  being  at  Jacksonville  and  other  places  in  Florida, 
and  Decatur  in  Alabama,  in  1888. 

In  South  America  yellow  fever  appeared  for  the  first  time 
in  1740.  In  1849  the  disease  was  imported  into  Brazil,  and 
has  since  then  been  endemic.  Peru  and  the  Argentine  Republic 
have  also  suffered  several  severe  visitations  of  yellow  fever  since 
1854. 

On  the  west  coast  of  Africa,  yellow  fever  seems  to  be  en- 
demic in  the  peninsula  of  Sierra  Leone,  where  it  has  been  fre- 
quently observed  since  1816.  It  has  also  prevailed  epidemically 
in  Senegambia  and  a  number  of  the  islands  off  the  northern 
portion  of  the  west  African  coast.  In  Europe,  Spain  and  Por- 
tugal have  been  the  only  countries  to  surfer  from  yellow-fever 
epidemics. 

Although  the  causes  of  yellow  fever  cannot  be  definitely 
stated,  it  is  well-known  that  it  only  occurs  endemically  within 
the  tropics,  and  prevails  epidemically  elsewhere  only  during  the 
summer.  Of  180  epidemics  observed  in  the  United  States  and 
Bermudas,  154  began  in  July,  August,  and  September.  Of  the 
remaining  26,  none  began  in  the  six  months  from  November  to 
April. 

A  temperature  of  26°  C.  and  a  high  humidity  are  gener- 
ally considered  essential  to  produce  an  outbreak  of  the  disease. 
Of  other  necessary  meteorological  conditions  nothing  is  known. 

That  the  specific  cause  of  yellow  fever  is  a  micro-organism 
appears  probable  from  a  consideration  of  the  clinical  history  of 
the  disease  and  its  mode  of  propagation.  Up  to  the  present 
time,  however,  none  of  the  various  organisms  described  as  causa- 
tive have  made  good  the  claims  advanced  by  their  discoverers. 
Surgeon-General  Sternberg  has  shown  that  neither  the  organism 
of  Freire,  of  Carmona,  of  Babes,  of  F.  S.  Billings,  of  Finlay, 
or  of  Gibier  is  the  true  cause  of  yellow  fever. 

It  seems  to  be  well  established  that  the  most  filthy  and 


366  TEXT-BOOK   OF   HYGIENE. 

insanitary  portions  of  cities  are  those  principally  ravaged  by 
yellow  fever.  The  author  is  convinced  from  personal  observa- 
tion in  Savannah,  Memphis,  and  New  Orleans,  that  filth  is  one 
of  the  principal  'factors  in  the  spread  of  yellow  fever.  This 
opinion  is  also  forcibly  expressed  by  many  of  the  most  eminent 
authorities  on  the  subject. 

Yellow  fever  is  not  endemic  within  the  limits  of  the  United 
States,  and  has  probably  never  originated  here.  The  instances 
in  which  it  has  appeared  to  do  so  may  be  explained  by  the  per- 
sistence of  the  morbific  agent  through  one  or  more  winters,  or 
by  a  new  importation  which  has  escaped  observation. 

Yellow  fever  frequently  breaks  out  on  shipboard  and  causes 
much  loss  of  life.  There  is  no  evidence  that  it  originates  on 
ships ;  it  is  only  acquired  after  intercourse  with  an  infected  ship 
or  infected  place. 

The  question  of  the  personal  contagion  of  yellow  fever  has 
been  decided  negatively.  The  disease  is  infectious  and  its  cause 
may  be  transported  in  fomites,  but  persons  sick  with  the  disease 
do  not  communicate  it.  An  infected  atmosphere,  or  one  favor- 
able to  the  poison,  is  necessary  to  the  propagation  of  the  disease. 

The  preventive  measures  indicated  against  yellow  fever 
appear  from  the  foregoing:  they  are  strict  sanitary  inspection  to 
prevent  the  introduction  of  a  person  sick  with  the  disease ;  to 
prevent  the  introduction  of  clothing  or  other  fomites  from  a 
suspected  locality  without  thorough  disinfection,  and  such  a  con- 
dition of  public  and  private  sanitation  as  will  prevent  the  devel- 
opment of  the  poison,  should  the  latter,  perchance,  be  introduced. 

When  the  disease  becomes  epidemic  in  a  city,  the  inhabi- 
tants should  be  removed  to  temporary  camps  beyond  the  infected 
area.  The  experience  of  the  city  of  Memphis  in  1879,  and  of 
various  localities  in  Florida  in  1888,  encourages  the  hope  that 
by  prompt  depopulation  of  cities  and  strict  enforcement  of  sani- 
tary measures  in  the  camps  the  terrors  of  yellow  fever  can  be 
largely  averted.  The  sick  should  be  promptly  isolated,  and  no 
one  except  attendants  permitted  to  have  intercourse  with  them. 


SCARLET   FEVER   AND   MEASLES.  367 

SCARLET    FEVER   AND    MEASLES. 

The  early  history  of  these  two  contagious  eruptive  fevers  is 
inextricably  blended  together.  Up  to  the  latter  half  of  the 
seventeenth  century  the  distinction  between  the  two  was  not 
made  by  writers.  Sydenham  was  among  the  first  who  clearly 
separated  scarlet  fever  from  measles  and  gave  it  a  distinct  name. 
Since  the  great  English  Hippocrates,  the  essential  character  of 
scarlet  fever  has  been  recognized  by  all  physicians,  and  it  is  now 
never,  or  but  rarely,  confounded  with  measles. 

Of  the  two  diseases,  measles  is  somewhat  more  generally 
prevalent,  although  both  occur  usually  in  epidemics.  There  is 
hardly  a  country  in  which  measles  has  not  been  observed,  while 
the  continents  of  Asia  and  Africa  have  remained  measurably 
exempt  from  scarlet  fever  up  to  the  present  time,  although  epi- 
demics have  been  recorded  in  India  and  Japan. 

Hirsch  states  that  scarlet  fever  was  first  observed  in  this 
country  in  1735,  at  Kingston,  Mass.,  quoting  as  authorities  Dr. 
Douglass,  of  Boston,  and  Dr.  Golden,  of  New  York.  The 
latter,  however,  in  a  letter  to  Dr.  Fothergill,1  clearly  describes 
diphtheria,  and  not  scarlet  fever.  Its  distribution  is  now  general, 
but  it  is  said  to  be  much  milder  in  the  southern  than  in  other 
portions  of  the  United  States.  The  prevalence  of  measles  is  not 
limited  to  any  geographical  section. 

Epidemics  of  measles  usually  begin  during  cold  weather. 
Of  530  epidemics  observed  in  Europe  and  North  America,  339 
occurred  during  the  colder  and  191  during  the  warmer  months. 
In  213  of  these,  the  height  of  the  epidemic  occurred  135  times 
in  winter  and  spring,  and  only  78  times  during  summer  and 
autumn.  Scarlet  fever  epidemics  occur  more  frequently  in 
autumn  than  at  any  other  season. 

The  cause  of  scarlet  fever  or  of  measles  is  not  to  be 
sought  in  climatic  influences,  insanitary  surroundings,  or  special 
natural  conditions  of  air,  water,  or  soil.  Both  diseases  are 
contagious  and  infectious,  and  the  contagion  is  transmitted  either 

1  Medical  Observations  and  Inquiries,  vol.  i,  p.  211.    London,  1776. 


368  TEXT-BOOK   OF   HYGIENE. 

by  fomites  (clothing,  letters,  etc.),  infected  air,  drinking-water, 
or  milk. 

Several  observers  have  claimed  the  discovery  of  the  specific 
organism  of  scarlet  fever,  but  no  trustworthy  evidence  has  yet 
been  furnished  that  the  problem  is  solved.  On  a  previous  page 
(93)  reference  has  been  made  to  the  probable  connection  between 
a  disease  of  milk-cattle  and  scarlet  fever. 

The  measures  for  the  prevention  of  both  diseases  are  isola- 
tion and  thorough  disinfection. 

DIPHTHERIA. 

Under  the  names  of  Syriac  and  Egyptian  ulcers,  Areta-us, 
a  writer  of  the  second  century,  described  various  forms  of  malig- 
nant sore  throat.  The  disease  now  called  diphtheria  prevailed  at 
various  places  in  Europe  during  the  Middle  Ages.  In  this  country 
it  was  first  observed  about  the  middle  of  the  last  century,  and 
in  1771  Dr.  Samuel  Bard,  of  New  York,  described  it  very 
accurately.  Although  repeated  severe  outbreaks  occurred  in 
Europe  in  the  early  part  of  the  present  century,  it  was  not  until 
1857  that  it  again  attracted  attention  by  its  epidemic  prevalence 
in  the  United  States.  Since  that  time  it  has  spread  throughout 
the  country,  and  is  at  present  one  of  the  most  generally  diffused, 
as  well  as  one  of  the  most  fatal,  of  the  contagious  diseases.  In 
certain  epidemics  its  malignancy  is  very  marked,  while  in  others 
it  seems  to  be  a  rather  mild  affection. 

Diphtheria  is  personally  contagious;  it  may  be  transmitted 
by  inoculation,  as  well  as  by  inhaling  an  infected  atmosphere. 
The  infecting  agent  is  most  probably  the  micro-organism  first 
described  by  Lofner.  The  bacillus  cannot  always  be  demon- 
strated, and  is,  further,  likely  to  be  confounded  with  non-patho- 
genic organisms  possessing  similar  morphological  characters. 

The  question  as  to  the  identity  of  diphtheria  and  croup  is 
not  merely  a  clinical  one,  but  has  an  important  bearing  upon 
preventive  medicine.  If  croup  is  a  non-contagious  and  non- 
infectious  disease,  as  is  held  by  many,  no  precautions  will  be 


DENGUE.  369 

necessary  to  prevent  its  spread  to  healthy  persons.  If,  on  the 
other  hand,  diphtheria  and  croup  are  identical  in  nature,  the 
danger  of  infection  is  equally  great  in  both  diseases.  Inasmuch 
as  it  is  frequently  impossible  to  positively  decide  upon  a  diagnosis, 
it  would  be  well  to  consider  the  identity  of  the  two  diseases  as 
established,  and  act,  as  far  as  preventive  measures  are  concerned, 
as  if  all  were  cases  of  diphtheria. 

Diphtheria  is  inoculable  upon  animals,  and  may  through 
this  medium  be  transmitted  to  man. 

Persons  sick  with  diphtheria  should  be  carefully  isolated  ; 
no  one  but  the  immediate  attendants  should  be  allowed  to  come 
in  contact  with  the  patients.  Table  utensils,  bedding,  and  cloth- 
ing used  by  the  sick  should  be  thoroughly  disinfected  by  steam 
or  boiling  water  before  being  used  by  others.  Intimate  contact 
with  the  sick,  such  as  kissing,  should  be  strictly  prohibited. 
There  seems  no  room  to  doubt  that  the  virus  of  the  disease  can 
also  be  carried  in  the  clothing.  Hence,  physicians  and  nurses 
should  be  especially  careful  in  personally  disinfecting  themselves 
after  contact  with  a  case  of  diphtheria.  After  death  or  recovery 
of  the  patient,  the  apartment  occupied  during  the  illness  should 
be  disinfected  with  chlorine  or  sulphurous-acid  gas. 

Children  recovering  from  diphtheria,  scarlet  fever,  measles, 
or  small-pox,  should  not  be  permitted  to  attend  school  for  at 
least  four  weeks  after  recovery.  It  is  believed  that  there  is 
danger  of  infection  for  a  period  about  as  long  as  this,  and,  besides, 
the  patients  are  apt  to  be  weakened  from  the  effects  of  the  dis- 
ease, and  not  able  to  resist  the  strain  of  continuous  mental  effort. 

DENGUE. 

The  disease  known  as  break-bone  fever,  dandy  fever,  and 
by  various  other  names,  was  first  observed  in  the  United  States 
in  1780  by  Dr.  Benjamin  Rush.  Dr.  Rush  describes  an  epi- 
demic which  prevailed  during  the  summer  and  early  autumn  of 
that  year  under  the  name  of  "  bilious  remittent  fever,"  but  the 
symptoms  of  the  disease  hardly  leave  any  doubt  that  it  was 


24 


370  TEXT-BOOK    OF   HYGIENE. 

dengue.  In  1779  and  1780  it  was  also  observed  on  the  Coro- 
mandel  coast,  in  Egypt,  and  on  the  island  of  Java.  In  1784  to 
1788  dengue  also  prevailed  in  various  cities  of  Spain.  In  1818 
an  epidemic  appeared  in  Lima,  in  which  nearly  every  one  of  the 
70,000  inhabitants  was  attacked. 

In  1824-25  the  disease  again  prevailed  widely  in  India, 
where  it  was  known  as  the  "  three-day  fever."  Isolated  out- 
breaks occurred  in  that  country  until  1853,  when  it  again  ap- 
peared as  a  wide-spread  epidemic,  and  in  1872  another  epidemic 
outbreak  occurred  in  the  East,  extending  from  Eastern  Africa 
to  Arabia,  India,  and  China. 

In  1826  an  epidemic  of  dengue  appeared  in  Savannah,  and 
in  the  following  two  years  spread  over  the  southern  portion  of 
the  United  States  and  the  West  Indies,  reaching  the  northern 
coast  of  South  America.  In  1845  to  1849  the  disease  was 
observed  in  Rio  Janeiro;  in  1848  to  1850  in  the  South  Atlantic 
and  Gulf  States.  In  1854  it  was  observed  in  Southern  Alabama, 
and  in  the  same  year  in  the  West  Indies.  In  1873  another 
epidemic  appeared  in  the  lower  Mississippi  Valley,  and  in 
1880  an  outbreak  of  some  extent  occurred  in  New  Orleans, 
Charleston,  and  other  places  on  the  Gulf  and  South  Atlantic 
coasts. 

Dengue  always  begins  in  the  summer  or  early  autumn,  and 
ceases  abruptly  with  the  advent  of  cold  weather.  It  is  almost 
exclusively  limited  to  hot  countries.  It  spreads  with  extreme 
rapidity  wherever  it  appears.  It  is  not  contagious ;  the  man- 
ner of  its  propagation  is  not  known.  The  susceptibility  to  the 
disease  appears  to  be  almost  universal ;  it  frequently  prostrates 
the  majority  of  the  inhabitants  where  an  outbreak  occurs. 
During  the  epidemic  in  Calcutta  in  1871-72,  75  per  cent,  of  the 
population  were  attacked.  In  the  United  States  similar  epi- 
demics have  been  repeatedly  observed. 

Dengue  is  rarely  fatal.  It  seems  to  be  propagated  through 
the  atmosphere.  No  measures  of  prevention  are  known  or 
available. 


EPIDEMIC  INFLUENZA.  371 

EPIDEMIC  INFLUENZA. 

Accounts  of  epidemic  influenza  can  be  traced  back  to  the 
year  1.173,  when  the  disease  was  observed  coincidently  in  Italy, 
Germany,  and  England.  It  has  prevailed  epidemically,  at  vary- 
ing intervals,  to  the  present  time.  In  the  fourteenth  century 
3  epidemics  are  recorded ;  in  the  fifteenth,  4 ;  in  the  sixteenth, 
7 ;  in  the  seventeenth,  46.  Of  these,  15  were  very  extensive, 
some  of  them  prevailing  over  both  hemispheres  contempo- 
raneously. 

On  the  American  continent  influenza  was  first  recorded  in 
1627,  when  it  prevailed  in  New  England,  where  it  again  broke 
out  in  1625.  Following  this  there  is  no  notice  of  the  disease 
in  America  until  1732,  when  an  epidemic  began  in  the  New 
England  States,  which  extended  over  the  entire  globe.  Epi- 
demics occurred  during  the  remainder  of  the  eighteenth  cen- 
tury in  1737,  1757,  1761,  1767,  1772,  1781,  1789,  and  1798. 
During  the  present  century  the  disease  has  prevailed  more  or 
less  extensively  in  this  country  at  thirteen  different  times,  the 
last  epidemic  of  any  considerable  extent  being  in  1879. 

In  November,  1889,  an  epidemic  began  in  Russia  which 
rapidly  spread  throughout  Northern  Europe,  reaching  the  United 
States  about  the  beginning  of  1890,  recurring  in  1891  and  1892. 
The  epidemic  was  complicated  in  many  cases  by  pneumonia  of  a 
fatal  character.  The  disease  manifested  itself  in  two  principal 
forms,  the  catarrhal  and  the  nervous.  Weichselbaum,  of  Vienna, 
claims  to  have  discovered  a  micro-organism  which  he  believes  to  be 
the  cause  of  the  affection,  but  this  claim  has  not  yet  been  verified. 

A  curious  feature  of  epidemics  of  influenza  is  the  coinci- 
dent occurrence  of  outbreaks  of  a  somewhat  similar  affection 
among  animals,  horses  and  dogs  being  especially  attacked. 

Influenza  is  an  acute,  specific,  infectious  disease,  not  di- 
rectly contagious.  The  infection  is  apparently  produced  or  trans- 
mitted in  the  air.  The  disease  frequently  appears  over  a  large 
area  of  country  almost  simultaneously.  Peculiarities  of  climate, 
season,  meteorological  conditions,  geological  formation,  or  racial 


372  TEXT-BOOK   OF   HYGIENE. 

characteristics  have  no  apparent  influence  upon  the  causation  or 
spread  of  the  disease.  It  occurs  more  frequently  in  the  winter 
and  spring  than  during  the  summer  or  autumnal  months.  The 
investigation  into  the  epidemic  of  influenza  among  horses,  re- 
ferred to  in  a  previous  chapter,1  seems  to  indicate,  however,  that  a 
moist  and  impure  atmosphere  intensifies  the  disease. 

No  measures  of  prophylaxis  can  be  indicated  except  avoid- 
ance of  anything  tending  to  depress  the  vital  powers. 

EPIDEMIC    CEREBRO-SPINAL   MENINGITIS. 

This  disease  was  first  recognized  in  Geneva  in  1805.  In 
the  following  year  it  was  noted  in  various  places  in  the  United 
States.  Both  in  Europe  and  this  country  localized  outbreaks 
of  the  disease  occurred  between  the  dates  above  mentioned  and 
1816.  At  this  time  the  disease  seemed  to  die  out  altogether, 
but  in  1822  it  re-appeared  in  various  parts -of  Europe  and 
America. 

Cerebro-spinal  meningitis  appeared  in  1857  in  the  south- 
west of  France,  and  during  the  following  ten  years  spread  over 
a  large  part  of  the  country.  Algiers,  Italy,  Denmark,  and  Ire- 
land were  also  visited  by  the  scourge.  In  1854  and  1861 
Sweden  experienced  its  ravages,  and  in  1859  Norway  was 
invaded  by  the  disease,  which  continued  for  nearly  a  decennium 
in  the  latter  country.  From  1860  to  1867  the  disease  prevailed 
in  Holland,  Portugal,  Germany,  Ireland,  and  Russia. 

After  the  termination  of  what  may  be  called  the  first  epi- 
demic, in  1816,  cerebro-spinal  meningitis  was  not  again  observed 
in  this  country  until  1842.  In  the  eight  years  succeeding,  it 
prevailed  epidemically  throughout  almost  the  whole  United 
States.  From  1861  to  1873  it  was  noted  frequently  in  various 
parts  of  the  country.  Since  the  latter  year  the  reports  of  its 
occurrence  in  this  country  have  been  limited  to  sporadic  cases 
or  localized  outbreaks. 

Cerebro-spinal   meningitis  is  an  acute  infectious   disease, 

1  Chapter  I,  p.  29. 


SYPHILIS.  373 

very  fatal  in  its  tendency.  It  is  probably  not  personally  con- 
tagious. Climate  has  no  influence  upon  its  origin,  but  season 
seems  to  stand  in  a  positive  relation  to  its  causation.  About 
three-fourths  of  the  epidemics  noticed  have  occurred  during  the 
winter  and  spring  months.  The  disease  seems  to  show  no 
preference  for  peculiarities  of  topographical  or  geographical 
formation.  Overcrowding,  overwork,  and  uncleanliness  have 
an  important  influence  in  determining  an  outbreak.  It  is 
especially  a  disease  of  youth  and  adolescence.  Out  of  975 
cases  occurring  in  New  York  only  150  were  over  20  years  of 
age,  while  of  the  remainder  665  were  under  10. 

The  prophylactic  measures  to  be  adopted  against  cerebro- 
spinal  meningitis  consist  in  careful  attention  to  the  sanitary 
conditions  of  dwellings  and  streets,  avoidance  of  overwork  and 
overcrowding  during  times  of  epidemic,  isolation  of  the  sick, 
and  disinfection  of  the  sick-room  after  the  termination  of  the 
disease. 

SYPHILIS. 

In  the  year  1494,  Charles  VIII,  of  France,  in  command  of 
a  large  army  invaded  Italy,  and  early  in  the  following  year  be- 
sieged Naples.  During  the  investment  of  the  city  a  very  severe 
disease,  characterized  by  ulcers  of  the  genitals,  violent  pains  in 
the  head  and  limbs,  and  generalized  cutaneous  eruptions  broke 
out  among  the  besiegers  and  spread  rapidly  throughout  the 
army  and  civil  population.  On  the  return  of  the  army  to  France, 
after  the  termination  of  the  war,  the  disease  rapidly  spread 
throughout  Europe,  and  the  literature  of  the  early  part  of  the 
sixteenth  century,  both  medical  and  lay,  teems  with  references 
to  it. 

From  the  locality  and  other  circumstances  connected  with 
its  epidemic  appearance  the  disease  acquired  various  names. 
Thus,  the  French  called  it  morbus  Neapolitanus,  or  mal  d  'Italic, 
while  the  Italians  termed  it  morbus  Gallicus,  or  mala  Franzos. 
At  a  very  early  period  it  was,  however,  clearly  recognized  that 
the  disease  was  communicated  during  sexual  intercourse,  and 


374  TEXT-BOOK   OF   HYGIENE. 

hence  it  was  usually  described  in  medical  writings  under  the 
name  lues  venerea,  while  in  the  popular  literature  it  still  figured 
as  the  Frenchman's  disease  (morbus  Gallicus).  The  name  syphilis 
was  first  used  in  a  poem  descriptive  of  the  disease,  written  in 
1521  by  Fracastor,  a  physician  of  Verona. 

The  extraordinary  outbreak  of  the  disease  toward  the  end 
of  the  fifteenth  century  led  to  many  speculations  concerning  its 
origin.  As  it  attacked  persons  in  all  ranks  and  conditions  of 
life,  "  sparing  neither  crown  nor  cross,"  in  the  words  of  a  con- 
temporary poet,  the  favorite  explanation  was  that  meteorological 
influences  had  much  to  do  with  its  causation.  Many  ascribed 
it  to  the  malign  influence  of  the  stars.  The  Neapolitans  attrib- 
uted it  to  the  wickedness  of  their  enemies,  the  French,  while 
the  latter  laid  the  blame  on  the  filth  and  immorality  of  the 
Italians.  The  Spaniards  claimed  that  it  had  been  imported  from 
America  by  Columbus,  whose  first  expedition  returned  to  Europe 
in  1493.  There  are  records,  however,  which  prove  that  the  dis- 
ease already  existed  in  Italy  in  the  latter  year.  In  other  parts 
of  Europe  the  Jews,  who  had  been  driven  out  of  Spain:  by  the 
terrors  of  the  Inquisition,  were  accused  of  this,  as  of  many  other 
misfortunes  which  befell  the  people.  When  it  was  definitely 
established  that  the  disease  was  communicated  almost  solely  by 
sexual  intercourse,  the  theory  of  its  transatlantic  origin  became 
very  popular.  It  is  characteristic  of  human  nature  to  refer 
the  origin  of  troubles  resulting  from  its  own  vices  to  some  other 
source,  if  possible.  This  theory  of  the  American  origin  of 
syphilis  is  still  held  by  some  writers.  Within  a  few  years,  Dr. 
Joseph  Jones,  of  New  Orleans,  claims  to  have  found  evidences 
of  syphilitic  disease  in  the  skulls  and  other  bones  from  some  of 
the  prehistoric  Indian  mounds  in  Mississippi.  These  observa- 
tions of  Dr.  Jones  have,  however,  not  yet  been  verified  by  others. 

Although  the  first  great  epidemic  of  syphilis  is  clearly  trace- 
able to  the  period  between  the  years  1493  and  1496,  an  ex- 
amination of  the  older  literature  reveals  many  descriptions  of 
disease  which  can  only  be  explained  by  assuming  them  to  refer 


SYPHILIS.  375 

to  syphilis.  The  Old  Testament  Scriptures  contain  numerous 
references  to  diseases  of  the  genital  organs.  In  most  instances 
these  troubles  are  ascribed  to  the  wrath  of  God,  although  in 
some  cases  a  pretty  shrewd  hint  is  given  as  to  the  causation  of 
the  affections.  Finaly1  remarks  that  the  Hebrew  word  trans- 
lated in  all  versions  of  the  Bible  by  "flesh"  signifies  also  the 
virile  member.  In  this  light,  the  references  in  Leviticus,  XIII— 
XV;  Numbers, XXV,  1-9,  XXXI,  16-1 8;  Deuteronomy,  IV,  3 ; 
Joshua,  XXII,  17 ;  I  Samuel,  V,  6,  9,  12 ;  Psalms,  CVI,  28-30  ; 
I  Corinthians,  X,  8;  Ephesians,  II,  11 ;  and  Colossians,  II,  13, 
receive  a  new  interpretation.  Numerous  innuendoes  in  the 
Latin  classics,  and  more  or  less  exact  descriptions  in  the  medical 
writings  of  Greece,  Rome,  China,  and  India,  leave  no  room  for 
doubt  that  venereal  diseases,  and  probably  among  them  syphilis, 
have  existed  from  the  earliest  times. 

At  the  present  day  syphilis  is  the  most  widely  prevalent  of 
all,  contagious  diseases.  In  1873  Dr.  F.  R.  Sturgis  estimated 
that  in  New  York  1  person  out  of  every  18  suffered  from  it. 
This  is  considered  a  moderate  estimate.  Dr.  J.  Wm.  White, 
of  Philadelphia,  pronounces  the  opinion  that  "not  less  than 
50,000  people  of  all  classes  in  that  city  are  affected  with  syphilis." 
On  this  basis  Gihon  estimates  the  number  of  syphilitics  in  the 
United  States  at  one  time  at  2,000,000.2 

The  disease  is  transmitted,  in  the  vast  majority  of  cases, 
during  the  performance  of  the  sexual  act,  but  there  are  numerous 
other  ways  in  which  it  may  be  and  frequently  is  communicated. 
In  the  special  literature  of  the  subject  are  records  of  many  cases 
in  which  the  disease  was  acquired  through  a  kiss,  a  bite,  the  act 
of  suckling  (from  infant  to  nurse,  and  conversely),  using  a  pipe, 
glass-blowers'  mouth-piece,  the  finger  of  a  midwife,  the  instru- 
ments of  the  dentist  or  surgeon,  inoculation  of  syphilitic  secretion 
mixed  with  saliva  in  the  process  of  tattooing,  and  many  other 
ways.  Numerous  cases  have  been  reported  where  physicians  were 
inoculated  on  the  finger  while  examining  a  syphilitic  patient. 

1  Arch.  f.  Dermat.  u.  Syphilis,  II  Jahrg.    1  Heft.,  p.  126. 

»  The  Prevention  of  Venereal  Diseases  by  Legislation,  Sanitarian,  June,  1882. 


376  TEXT-BOOK   OF    HYGIENE. 

The  prophylactic  measures  which  suggest  themselves  from 
a  consideration  of  the  nature  of  the  disease  are  isolation  of  those 
infected,  regular  inspection  of  the  class  of  persons  through  whom 
the  disease  is  most  frequently  transmitted,  t'.e.,  prostitutes,  and 
individual  precautions  against  acquiring  it.  Greater  attention 
to  cleanliness  of  the  genital  organs  on  the  part  of  those  indulg- 
ing in  promiscuous  intercourse  would  aid  largely  in  reducing 
the  number  of  cases  of  syphilis. 

DISEASES   OF   ANIMALS   COMMUNICABLE   TO   MAN. 

Sheep-pock. — This  is  a  highly  contagious  and  infectious 
disease  of  sheep,  resembling,  in  its  symptoms,  course,  and  fatality, 
small-pox  as  it  occurs  in  the  human  race.  It  is  believed  by 
Bellinger  to  be  different  from  the  form  of  small-pox  produced 
in  sheep,  goats,  horses,  and  other  animals  by  the  inoculation  of 
human  small-pox.  Sheep-pock  can  be  inoculated  upon  other 
animals  and  man,  but  only  produces  a  local  disease  at  the  point 
of  inoculation  in  the  latter.  Sheep  may  be  protected  against 
this  disease  by  inoculation  with  sheep-pock  virus  (ovination),  or 
by  vaccination  with  vaccine  lymph.  The  peculiarity  of  sheep 
vaccinia  is  that  it  is  a  more  or  less  generalized  disease,  the 
pustules  being  distributed  over  the  body.  Sheep-pock,  when 
inoculated  upon  human  beings,  does  not  produce  a  generalized 
infectious  disease,  but  remains  entirely  local. 

Actinomycosis. — Veterinarians  have  frequently  observed  a 
disease  attacking  the  jaws  of  cattle  and  producing  tumors,  often 
with  ulcerated  surfaces.  The  bone  is  usually  involved.  The 
disease  has  heretofore  been  generally  considered  a  sarcomatous 
growth.  It  is  not  seldom  observed  among  the  cattle  in  the 
western  stockyards,  where  it  is  known  in  the  vernacular  as 
"  swell-head."  Recent  investigations  by  Ponfick  have  shown 
that  the  growth  consists  of  a  vegetable  parasite  (actinomyces), 
and  that  it  is  inoculable  upon  other  animals,  and  may  be 
conveyed  to  man.  A  considerable  number  of  cases  have  been 
observed  in  human  beings  in  Germany,  where  the  disease  was 


DISEASES   OF    ANIMALS   COMMUNICABLE   TO   MAN.  377 

first  described  by  Ponfick,  and  .very  recently  4  cases  have 
been  reported  in  this  country.1 

Bovine  Tuberculosis  (Perlsucht). — In  cattle,  tuberculosis 
occurs  in  two  forms,  miliary  tubercles  and  cheesy  masses  in  the 
lungs,  and  firm,  pearly  nodules  on  the  serous  membranes. 
These  nodules  do  not  break  down,  but  may  become  calcified. 

Bovine  tuberculosis  is  a  frequent  disease  among  cows  kept 
in  damp,  dark,  and  ill-ventilated  stables.  The  disease,  which  is 
essentially  the  same  as  human  tuberculosis,  tubercle  bacilli 
being  present  in  the  neoplasms,  is  believed  by  many  to  be  trans- 
missible to  human  beings  by  means  of  the  milk  or  flesh  of 
tuberculous  animals.  The  sale  of  the  meat  of  tuberculous  cattle 
should  be  prohibited. 

Rabies. — Hydrophobia  in  the  brute,  and  its  communi- 
cability  to  man  through  a  bite,  has  been  known  from  the 
remotest  antiquity.  It  occurs  in  dogs,  foxes,  wolves,  horses, 
and  other  animals,  and  may  be  transmitted  from  any  of  them  to 
human  beings. 

The  contagium  of  rabies,  the  infective  poison,  is  contained 
principally  in  the  saliva,  and  is  usually  inoculated  by  the  teeth 
of  the  mad  animal. 

Pasteur  has  shown  that  the  greatest  virulence  of  the  rabies 
poison  resides  in  the  brain  and  spinal  cord  of  the  animal  suffer- 
ing from  the  disease.  By  cultivation  of  this  virus,  the  nature 
of  which  has  not  yet  been  definitely  determined,  its  virulence 
could  be  diminished,  and  by  inoculation  of  men  and  animals 
with  the  attenuated  virus  protection  against  the  disease  could 
be  secured.  The  fact  seems  likewise  established  that  the  period 
of  incubation  of  the  inoculation-rabies  is  much  shorter  than  that 
acquired  in  the  usual  way  by  bites  of  rabid  animals.  Hence, 
inoculation  with  the  attenuated  virus  protects  the  bitten  individ- 
ual against  the  fatal  outbreak  of  the  unmodified  disease. 

Anthrax. — Anthrax,   or  splenic  fever  (milzbrand),   is  an 

1  Boston  Med.  and  Surg.  Journal,  Oct.  16,  1884,  p. 377,  and  Journ.  Am.  Med.  Ass'n,  Nov.  27, 
1886.  Also,  N.  E.  Med.  Monthly,  Sept.  15, 1886. 


378  TEXT-BOOK   OF   HYGIENE. 

acute,  highly  contagious  and  infectious  disease  of  herbivorous 
animals,  which  may  be  transmitted  by  Inoculation  or  the 
ingestion  of  the  virus  to  other  animals  and  to  man. 

The  disease  is  due  to  a  minute  vegetable  organism  which 
is  found  in  the  blood  and  tissues  of  the  diseased  animals.  This 
organism,  bacillus  antJiracis,  was  first  discovered  by  Pollender, 
and  has  been  thoroughly  investigated  by  Davaine,  Pasteur, 
Koch,  and  others. 

Inoculation  of  these  bacilli  or  their  spores  always  produces 
the  disease  in  susceptible  animals.  Skins  of  animals  not  infre- 
quently contain  the  virus,  which  may  then  gain  access  to  the 
blood  of  persons  engaged  in  handling  them.  Knackers, 
butchers,  wool-sorters,  and  other  persons  liable  to  come  in 
contact  with  sick  animals,  or  handling  their  flesh  or  hides,  are 
subject  to  the  infection,  either  by  direct  inoculation  (through 
abrasions  of  the  skin,  etc.)  or  by  inhalation  of  the  spores  of  the 
bacillus.  An  intestinal  form  of  anthrax  in  man,  mycosis  intes- 
tinali-8,  is  sometimes  produced  by  the  consumption  of  meat  of 
animals  suffering,  when  killed,  of  splenic  fever.  Numerous 
instances  have  been  reported.  The  diagnosis  has  been  verified 
by  discovering  the  bacillus  of  anthrax  in  the  blood  and  various 
organs  of  the  individuals  attacked. 

In  view  of  the  dangerous  character  of  the  disease,  persons 
coming  in  contact  with  animals  suffering  from  anthrax  should 
be  warned  of  their  peril.  In  order  to  protect  other  animals  in 
a  herd,  strict  isolation  of  the  infected,  thorough  disinfection  of 
the  stables  occupied  by  them,  and  deep  interment  of  the  cadavers 
of  those  dead  from  the  disease  are  indicated. 

Glanders. — Glanders,  or  farcy,  is  a  very  fatal  contagious 
disease  of  horses  which  may  be  communicated  to  other  animals 
and  to  man.  The  cause  of  glanders  has  recently  been  discovered 
by  Loffler  to  be  a  bacillus  resembling  the  bacillus  tuberculosis. 
Pure  cultures  of  this  bacillus  were  inoculated  into  animals,  and 
followed  by  glanders  in  a  number  of  the  cases. 

The  infection  in  man  may  occur  either  upon  the  seat  of 


DISEASES   OF   ANIMALS   COMMUNICABLE   TO   MAN.  379 

excoriations  of  the  skin  or  mucous  membranes,  especially  those 
of  the  nose,  conjunctiva,  and  possibly  by  inhalation  of  infective 
particles  floating  in  the  air. 

Animals  with  glanders  should  be  promptly  killed  and  their 
cadavers  cremated  or  deeply  buried.  No  part  of  the  body  of 
any  animal  dead  with  glanders  should  be  allowed  to  be  used. 
Infected  stables  should  be  thoroughly  disinfected. 

[The  works  of  especial  value  to  students  who  desire  fuller 
information  upon  the  subjects  treated  in  this  chapter  are  the 
following : — 

Hirsch,  Handbuch  der  Historisch-Geographischen  Pathologic,  2te 
Aufl.,  Stuttgart,  1883. — Haeser,  Geschichteder  Epidemischen  Krankheiten. 
— Hecker,  The  Black  Death,  translated  b}'  B.  G.  Babington. — Rohlfs, 
Die  Orientalisohe  Pest. — Marson,  "  Small-pox,"  in  Reynolds's  System  of 
Medicine,  vol.  i. — Seaton,"  Vaccination  "ibid. — Trousseau,  Clinical  Medi- 
cine, vol,  i. — Fifth  Annual  Report  of  Illinois  State  Board  of  Health. — 
Hardaway,  Essentials  of  Vaccination. — Crookshank,  History  and  Pathol- 
ogy of  Vaccination, — Woodworth  and  McClellan,  Cholera  Epidemic  in 
United  States  in  1873.— Chailld,  "Report  of  Yellow  Fever  Commission," 
Annual  Report  National  Board  of  Health  for  1880. — Wood  and  Formad, 
"  Memoir  on  the  Nature  of  Diphtheria,"  ibid.,  1882. — Thompson,  Annals  of 
Influenza. — Stille,  Epidemic  Meningitis. — Mueller,  Die  Venerischen 
Krankheiten  im  Altherthum. — Lancereaux,  Traite  de  la  Syphilis. — 
Bollinger,  "  Ueber  Menschen  u.  Thierpockeii,"  etc.,  Samml.  klin.  Vortr., 
No.  116. — Ponfick,  Die  Actinomycose  des  Menschen. — Gamgee, "  Hydro- 
phobia and  Glanders,"  in  Rej^nolds's  System  of  Medicine,  vol.  i. — 
Bollinger,  "  Anthrax,"  in  Ziemssen's  Cyclopaedia,  vol.  iii. — E.  O.  Shakes- 
peare, Report  on  Cholera  in  Europe. — Surgeon-General  G.  M.  Stern- 
berg,  Etiology  and  Prevention  of  Yellow  Fever. — Ernest  Hart,  "  Water- 
borne  Cholera,"  Journ.  Am.  Med.  Ass'n,  July  1.  1893.] 


QUESTIONS   TO   CHAPTER  XIX. 

HISTORY  OF  EPIDEMIC  DISEASES. 

Of  what  advantage  is  the  study  of  the  history  of  epidemic  dis- 
eases ?  What  are  some  of  the  most  important  maladies  of  this  class  ? 
To  what  are  they  all  due  ? 

What  are  some  of  the  synonyms  of  the  Oriental  plague?  What 
are  some  of  its  characteristic  symptoms  ?  What  is  the  date  of  the  first 
clear  account  of  it  ?  How  long  did  this  epidemic  persist  ?  When  did  it 
make  its  second  incursion  into  Europe?  What  was  one  of  the  peculiar 
symptoms  of  this  epidemic  ?  What  was  its  estimated  mortality  ?  What 
were  some  of  its  moral  effects  ?  When  was  its  final  incursion  into 
Western  Europe?  What  minor  epidemics  of  it  have  there  been  since? 
When  was  the  last,  and  where  ?  Is  it  now  endemic  anywhere  ?  To 
what  was  its  origin  formerly  ascribed?  What  conditions  are  always 
present  when  the  plague  prevails?  What  is  another  evident  factor  in 
its  causation  ?  How  is  it  generally  transmitted  ?  Is  it  a  germ  disease  ? 
What  are  the  measures  of  prevention  therefore  indicated  ? 

What  is  the  sweating  sickness  ?  What  are  some  of  its  character- 
istic symptoms  and  peculiarities?  What  is  evidently  its  nature?  Is 
there  any  class  exempt  from  it  ?  What  favors  its  spread?  What  rela- 
tion has  it  to  cholera?  When  did  it  first  appear  in  England  ?  When  for 
the  last  time?  Where  has  it  appeared  since?  Have  there  been  many 
outbreaks  in  Europe  ? 

What  are  the  earliest  details  regarding  small-pox  ?  When  was  it 
supposed  to  have  been  introduced  into  Europe?  Who  made  the  first 
distinct  reference  to  it  in  medical  literature?  AVhen  ?  What  was  the 
estimated  mortality  from  this  disease  in  Europe  previous  to  the  intro- 
duction of  vaccination  ?  Where  has  it  been  very  fatal  in"  its  devastations 
in  recent  years  ?  What  other  countries  and  peoples  have  suffered  from 
it  ?  What  is  the  mortality  from  unmodified  small-pox  ?  How  is  the  dis- 
ease transmitted?  What  factors  are  necessary  to  cause  an  outbreak? 
What  may  carry  the  poison?  For  what  distance  about  a  patient  may 
the  air  be  infectious  ?  In  what  stages  of  the  disease  is  it  contagious  ? 
What  races  are  more  commonly  attacked,  and  among  which  is  it  more 
fatal ? 

Does  one  attack  of  small-pox  always  confer  future  immunity  from 
(380) 


QUESTIONS   TO   CHAPTER    XIX.  381 

the  disease  ?  Wherein  is  the  popular  belief,  that  persons  suffering  from  an 
acute  or  chronic  disease  are  less  liable  to  incur  small-pox  than  the  healthy, 
at  fault  ?  Which  maladies  are  most  likely  to  afford  this  immunity  ?  When 
does  such  immunity  appear  to  cease  ? 

When  do  epidemics  of  small-pox  usually  begin  ?  In  what  seasons  do 
they  spread  most  rapidly?  Does  the  disease  spread  rapidly  at  first? 
Has  the  specific  organism  of  small-pox  been  certainly  discovered  ? 

When  was  the  first  attempt  to  limit  the  fatality  of  small-pox  by  in- 
oculation made  in  Europe?  When  was  the  practice  .introduced  into 
England,  and  by  whom  ?  What  were  the  details  of  the  method  as  then 
practiced  ?  What  were  the  characteristics  of  the  disease  thus  produced  ? 
Was  the  practice  altogether  without  danger  to  the  one  inoculated  ? 
What  other  grave  objection  was  there  to  such  inoculations  ?  When  was 
the  practice  of  inoculation  introduced  into  America,  and  by  whom  ? 
How  long  was  it  continued  in  England  and  in  America?  Where  was  it 
practiced  before  its  introduction  into  Europe? 

What  led  to  the  discovery  of  vaccination  ?  Who  first  practiced  it  ? 
When  ?  To  whom  is  due  the  merit  of  demonstrating  and  publishing 
the  value  of  vaccination  ?  When  did  he  perform  his  first  vaccination, 
and  with  what  results?  When  did  he  publish  the  first  pamphlet  in  rela- 
tion to  it  ?  When  was  vaccination  introduced  into  America,  and  by 
whom  ? 

What  is  the  relation  of  vaccinia  (cow-pox)  to  small-pox  ?  What  are 
the  symptoms  produced  in  the  case  of  a  successful  vaccination  ?  When 
•may  the  individual  be  considered  to  be  thoroughly  protected?  Is 
the  immunity  absolute  for  life?  What  is  the  character  of  an  attack 
of  small-pox  in  an  individual  who  has  once  been  vaccinated  ?  Does 
repeated  vaccination  increase  the  immunity  ?  What  effect  has  vaccina- 
tion had  on  the  mortality  from  small-pox  ?  On  the  prevalence  of  the 
disease  ? 

What  important  precaution  should  be  observed  in  all  vaccinations  ? 
Why  ?  When  should  children  be  vaccinated  ?  When  should  they  be  re- 
vaccinated  ?  What  are  some  of  the  peculiarities  following  upon  revacci- 
nation  ?  What  are  some  of  the  objections  urged  against  humanized 
virus  ?  Are  these  all  valid  ?  What  are  some  of  its  advantages  ?  How 
is  it  to  be  inoculated  ?  How  is  animal  virus  obtained  ?  How  is  it  to  be 
used  ?  In  what  way  do  the  results  from  using  it  differ  from  those  of 
humanized  virus  ? 

What  complications  are  likely  to  occur  in  the  course  of  the  vaccinia? 
What  are  some  of  the  causes  of  these  complications  ?  What  subjects  are 
unfavorable  ones  for  vaccination  ?  When  may  vaccination  be  properly 


382  QUESTIONS   TO   CHAPTER    XIX. 

delayed  ?     What  diseases  may  be  communicated  by  or  may  follow  vacci- 
nation ?     What  cases  should  be  promptly  revaccinated. 

What  besides  vaccination  is  highly  important  in  the  prophylaxis  of 
small-pox  ?  What  precautions  should  be  observed  in  the  care  of  one  sick 
with  small-pox  ?  What  are  the  best  disinfectants  for  such  cases  ?  When 
is  all  danger  of  infection  over  ? 

Where  is  Asiatic  cholera  endemic?  What  can  be  said  of  its  ravages 
there  ?  When  were  the  first  authentic  accounts  of  it  given  ?  When  did 
the  disease  first  become  epidemic  outside  of  India?  What  were  some  of 
the  countries  visited  ?  When  did  it  first  appear  in  England  ?  When 
and  where  in  America  ?  When  did  this  outbreak  from  India  end  ?  When 
did  it  again  become  pandemic,  and  how  long  before  it  again  reached  the 
United  States?  What  were  the  ports  through  which  it  entered?  How 
long  did  it  persist  in  this  country  ?  How  long  in  South  America  ?  When 
was  the  next  visitation  to  this  country  ?  What  parts  of  South  America 
were  first  invaded  at  this  time  ?  Where  else  was  cholera  raging  during 
these  periods,  and  where  was  it  practically  endemic  ? 

When  was  the  last  serious  importation  of  the  disease  into  this  country, 
and  by  what  port  did  it  enter?  Where  else,  and  when,  have  there  been 
important  epidemics  since  this  date  ?  What  does  the  history  of  all  these 
epidemics  demonstrate  ?  What  factors  must  concur  that  there  may  be 
an  epidemic?  What  is  the  specific  cause  of  cholera?  Who  discovered 
it?  When?  Is  the  disease  contagious?  How  is  it  spread ?  What  con- 
ditions seem  to  be  necessary  for  its  propagation  ?  When  do  outbreaks 
usually  occur,  and  when  do  they  subside  ?  Why  is  the  disease  endemic  in  . 
India  ?  How  do  these  conditions  predispose  the  victims  to  the  disease  ? 
Are  these  conditions  peculiar  to  India?  Where  else  may  they  exist  ? 

How  is  the  specific  organism  given  off  from  the  human  body  ?  How 
does  it  usually  gain  entrance  into  others  ?  What  evidence  is  there 
of  this  (see  chapter  on  Water)  ?  What  other  agencies  may  aid  in 
disseminating  the  disease  ? 

What  are  the  measures  of  prophylaxis  against  cholera  ?  How  can 
the  entrance  of  the  disease  into  a  community  be  prevented  ?  What 
measures  of  local  sanitation  may  be  even  more  effective  ?  Why?  How 
shall  the  drinking-water  and  food  be  rendered  harmless  ? 

How  may  one  guard  against  an  individual  predisposition  to  cholera? 
What  measure  of  personal  prophylaxis  is  useful  ?  What  is  the  rationale 
of  this  ?  What  disease  may  simulate  cholera  during  an  epidemic,  and 
to  what  is  it  often  due  ? 

In  times  of  cholera  epidemics,  what  sanitary  measures  are  to  be  es- 
tablished ?  What  disinfectants  are  to  be  used  ?  What  articles  are  to  be 


QUESTIONS   TO   CHAPTER   XIX.  383 

disinfected,  and  how  ?  What  are  some  of  the  objections  to  the  indis- 
criminate use  of  the  bichloride  of  mercury  ?  What  may  be  used  in  its 
stead  ?  What  does  Koch  recommend,  and  what  objection  is  there  to  its 
use  ?  What  plan  should  be  pursued  at  the  beginning  of  an  epidemic  ? 

When  was  relapsing  fever  first  described?  When  was  it  first 
observed  in  America?  When  did  it  last  appear  here?  What  predis- 
posing conditions  favor  it  ?  What  is  its  specific  exciting  cause  ?  Where 
is  the  germ  found  ?  What  are  the  preventive  measures  to  be  used  against 
relapsing  fever? 

How  long  has  typhoid  fever  been  known  as  a  distinct  disease? 
Where  is  typhoid  fever  common  ?  When  is  it  most  prevalent  ?  What 
persons  and  ages  are  most  subject  to  it?  To  what  is  the  disease  due? 
Where  is  it  found?  Is  the  disease  contagious?  Where  is  the  poison 
developed  ?  Does  it  arise  de  novo?  How  may  the  poison  be  conveyed 
to  human  beings  ?  What  prophylaxis  may  be  employed  against  typhoid 
fever?  What  are  the  requisites  for  prevention? 

When  were  the  earliest  authentic  accounts  of  typhus  fever  made  ? 
What  predisposing  conditions  favor  its  development  and  spread  ?  When 
is  it  more  prevalent  ?  By  what  is  it  limited  ?  Where  is  it  apt  to  occur  ? 
What  class  of  persons  is  most  likely  to  be  attacked?  Is  it  contagious? 
How  may  it  be  prevented  ?  What  measures  are  to  be  pursued  during  an 
outbreak  of  the  disease? 

Where  is  the  present  home  of  yellow  fever  ?  What  localities  are 
most  liable  to  epidemics  of  this  disease  ?  What  is  the  date  of  the  first 
authentic  account  of  it?  When  and  where  did  it  first  appear  in  the 
United  States?  Has  it  ever  originated  here  or  been  endemic?  How 
many  times  has  it  been  epidemic  in  this  country  in  the  last  two  centuries  ? 
When  and  where  was  the  last  epidemic  ?  In  what  season  do  epidemics 
occur?  In  what  climates  may  it  be  endemic?  What  climatic  conditions 
seem  to  be  necessary  for  an  outbreak  ?  What  is  probably  its  specific 
cause  ?  Has  this  been  discovered  ?  What  is  one  of  the  principal  factors 
in  its  spread  ?  Is  the  disease  contagious  ?  How  is  the  poison  conveyed  ? 
What  is  necessary  to  the  propagation  of  the  disease?  What  preventive 
measures  are  to  be  employed  against  yellow  fever  ? 

What  is  to  be  done,  should  the  disease  become  epidemic  in  a  city  ? 
Will  this  be  efficacious  in  most  cases? 

Who  first  distinguished  between  scarlet  fever  and  measles  ?  Which 
disease  is  more  prevalent  ?  What  countries  have  been  practically  exempt 
from  scarlet  fever?  When  was  scarlet  fever  first  observed  in  America? 
When  do  epidemics  of  measles  usually  begin?  When  of  scarlet  fever? 
What  is  the  exciting  cause  of  each  disease,  and  how  may  it  be  conveyed  ? 


384  QUESTIONS    TO   CHAPTER   XIX. 

Have  bad  hygienic  surroundings  an  influence  in  the  propagation  of  either 
disease  ?     What  are  measures  for  prevention  in  both  cases  ? 

How  old  is  the  history  of  diphtheria?  When  was  it  first  observed 
in  this  county  ?  When  did  it  again  prevail  epidemically  here  ?  How 
are  various  epidemics  marked  ?  Is  it  contagious  ?  How  may  it  be  con- 
veyed ?  What  is  the  exciting  cause?  Is  diphtheria  identical  with  croup? 
What  plan  should  be  pursued  for  prevention  regarding  the  two  diseases  ? 
Is  diphtheria  transmissible  to  animals  ?  What  precautions  should  be 
taken  with  a  person  sick  with  diphtheria?  How  long  should  children 
who  have  had  diphtheria,  scarlet  fever,  small-pox,  or  measles  be  detained 
from  school  ?  Why  ? 

What  is  dengue  ?  When  and  by  whom  was  it  first  observed  in  the 
United  States  ?  When  does  an  epidemic  begin,  and  when  does  it  stop  ? 
To  what  countries  is  the  disease  limited  ?  Is  it  contagious  ?  How  is  it 
propagated  ?  Who  are  susceptible  ?  What  are  the  measures  of  preven- 
tion that  may  be  employed?  Is  the  disease  fatal? 

What  is  the  date  of  the  earliest  accounts  of  epidemic  influenza? 
What  are  some  of  its  synonyms  ?  When  did  it  first  prevail  in  America? 
When  was  the  last  epidemic  ?  How  was  this  one  complicated  ?  Are  ani- 
mals subject  to  this  disease?  Is  it  contagious?  How  is  it  transmitted  ? 
When  is  it  most  prevalent  ?  What  are  the  measures  of  prophylaxis 
against  it  ? 

When  was  epidemic  cerebro-spinal  meningitis  first  recognized? 
When  did  it  appear  in  America?  When  was  the  first  epidemic  here? 
When  the  next?  When  the  last?  Is  it  contagious  or  infectious?  What 
is  its  tendency  ?  When  is  it  most  liable  to  occur?  What  influence  has 
climate  upon  it?  What  factors  seem  to  favor  an  outbreak  ?  What  ages 
are  most  subject  to  it?  What  is  the  prophylactic  treatment? 

When  and  where  does  syphilis  seem  to  have  had  its  origin?  Are 
there  any  traces  of  evidence  of  its  existence  before  this  ?  What  can  be 
said  of  its  comparative  prevalence  ?  How  is  it  usually  transmitted  ?  In 
what  other  ways  may  it  be  conveyed  ?  What  prophylactic  measures  are 
indicated  ? 

What  are  some  of  the  serious  diseases  of  animals  communicable  to 
man  ?  What  is  sheep-pock,  and  what  is  its  peculiarity  when  inoculated 
upon  human  beings  ? 

What  is  actinomycosis ?  What  are  some  of  the  synonyms?  To 
what  is  it  due  ? 

In  what  two  forms  does  tuberculosis  occur  in  cattle?  Is  it  common 
among  them?  How  is  it  related  to  human  tuberculosis?  How  may  it  be 


QUESTIONS  TO   CHAPTER  XIX.  385 

transmitted  to  man  ?     What  precautions  should  be  enforced  to  prevent 
this  transmission  ? 

What  is  rabies ?  How  is  it  transmitted?  Where  is  the  contagium 
contained?  Where  does  the  poison  of  greatest  virulence  reside?  How 
may  the  virus  be  cultivated,  and  what  changes  take  place  in  it  ?  How 
may  immunity  against  the  disease  be  produced?  Who  discovered  and 
advocated  this  method  of  inoculation? 

What  is  anthrax?  What  are  some  of  its  synonyms?  To  what 
is  it  due?  How  may  it  be  transmitted?  What  are  the  measures  of 
prophylaxis  against  it,  both  for  man  and  animals  ? 

What  is  glanders  ?  To  what  is  it  due  ?  How  may  infection  occur  ? 
What  should  be  done  with  animals  sick  with  this  disease  ?  What  else 
should  be  done  ? 

25 


CHAPTER  XX. 

ANTISEPTICS,  DISINFECTANTS,  AND  DEODORANTS. 

MUCH  confusion  exists  in  the  popular  mind,  and  even 
among  physicians,  as  to  the  exact  meaning  of  the  terms  at  the 
head  of  this  chapter.  By  many  they  are  used  synonymously,  and 
hence  frequently  give  rise  to  ambiguity  and  misunderstanding. 

Antisepsis,  which  is  so  frequently  confounded  with  disin- 
fection, should  be  more  accurately  defined  than  is  usual  by 
writers.  An  antiseptic  is  an  agent  which  retards,  prevents,  or 
arrests  putrefaction,  decay,  or  fermentation.  It  does  not  neces- 
sarily destroy  the  vitality  of  the  organisms  upon  which  these 
processes  depend.  An  antiseptic  may  also  arrest  the  develop- 
ment of  the  organisms  which  cause  infectious  diseases,  and  may 
hence  be  used  as  a  preventive  of  such  diseases.  But  antiseptics 
do  not  destroy  the  life  of  disease-germs,  and  hence  cannot  be 
relied  upon  when  such  organisms  are  present. 

By  disinfection,  in  the  proper  and  restricted  use  of  the  term, 
is  meant  the  destruction  of  the  specific  infectious  material  which 
causes  infectious  diseases.  If  the  view,  is  accepted  that  all  in- 
fectious diseases  are  due  to  micro-organisms  or  germs,  then  a 
disinfectant  is  equivalent  to  a  germicide.  In  sanitary  practice 
and  experimental  investigations  this  view  is,  in  fact,  adopted. 
In  testing  the  action  of  various  disinfecting  agents  upon  infec- 
tious material,  the  biological  test  is  the  one  universally  relied 
upon  by  experimenters,  and  no  observations  upon  disinfection 
based  upon  chemical  tests  alone  would  be  accepted  by  sanitarians 
as  conclusive.  It  may  therefore  be  assumed  for  practical  pur- 
poses that  no  agent  can  be  accepted  as  a  disinfectant  if  it  is  not 
also  a  germicide.  From  this  it  follows  that  disinfection,  to  be 
trustworthy,  must  be  thorough.  "  There  can  be  no  partial 
disinfection  of  infectious  material ;  either  its  infectious  power  is 
destroyed,  or  it  is  not.  In  the  latter  case  there  is  a  failure  to 
disinfect."1  Obviously,  also,  there  can  be  no  disinfection  in  the 

*  Report  of  Committee  on  Disinfectants  of  the  American  Public  Health  Association^).  236. 

(387) 


388 


TEXT-BOOK    OF   HYGIENE. 


absence  of  infectious  material.  Faecal  discharges,  a  diseased 
body  or  corpse,  clothing,  bedding,  an  apartment,  a  ship,  or  a 
hospital  ward  may  or  may  not  be  infected.  In  the  former  case 
we  may  speak  of  disinfecting  them ;  in  the  latter,  it  would  be  an 
inappropriate  use  of  the  word. 

Confusion  is  also  liable  to  arise  by  considering  disinfectants 
and  deodorizers  as  synonymous.  Deodorants  merely  remove 
offensive  odors,  and  may  not  possess  any  disinfecting  power 
whatever.  Thus,  one  of  the  most  efficient  disinfectants  at  our 
command  (mercuric  chloride)  is  not  a  deodorizer  at  all,  except 
by  preventing  putrefaction.  On  the  other  hand,  some  of  the 
most  effective  deodorants  have  only  a  subordinate  position  in  the 
scale  of  disinfectants. 

Careful  investigations  have  shown  that  there  is  a  wide 
divergence  between  various  disinfecting  agents  in  their  influence 
upon  disease-germs,  some  being  efficient  in  high  dilutions,  while 
others  require  to  be  brought  in  contact  with  the  germs  in  great 
concentration.  For  example,  mercuric  chloride  will  act  as  an 
efficient  poison  to  certain  disease-germs  (anthrax  spores)  in  the 
proportion  of  1  to  1000,  while  zinc-chloride  must  be  used  in  the 
proportion  of  1  to  5  (or  20  per  cent.). 

It  has  been,  further,  discovered  that  different  disease-germs 
present  varying  resisting  power  to  the  same  disinfecting  agent, 
some  being  easily  destroyed,  while  others  are  much  more  resistant. 
For  example,  the  following  table  shows  a  number  of  experiments 
made  by  Dr.  Meade  Bolton  for  the  American  Committee  on 

Disinfectants : — 

TABLE  XXX. 


ORGANISM. 

Chloride  of 
Lime. 

Mercuric 
Chloride. 

Carbolic  Acid. 

Typhoid  bacillus  

1  :  2000 

1:10,000 

1  :100 

Cholera  spirillum      .... 
Anthrax  spores     

1  :  2000 
1  :  100 

1:10,000 
1:1000 

1:100 
1  :50 

Staphylococcus  aureus  .     .     . 

1  :200 

(Uncertain.) 
1:100 

Staphylococcus  citreus 

1  :50 

1  :  100 

Staphylococcus  albus    . 

1  :200 

1  :100 

ANTISEPTICS,    DISINFECTANTS,    AND    DEODORANTS.  389 

Assuming  that  infectious  diseases  are  caused  by  micro- 
organisms, and  that  these  are  different  from  the  micro-organisms 
of  ordinary  decay  or  putrefaction,  it  can  be  readily  understood 
that  the  processes  of  organic  decomposition  may  themselves  act 
as  disinfectants.  It  is  known,  for  example,  that  when  a  fer- 
menting liquid  putrefies,  the  organisms  of  fermentation  disap- 
pear and  give  place  to  the  organisms  of  putrefaction  (bacterium 
termo,  etc.).  So,  likewise,  the  bacilli  of  anthrax  and  of  tuber- 
culosis are  killed  by  the  putrefactive  process,  if  this  takes  place 
in  the  absence  of  free  oxygen.  Furthermore,  the  reproduction 
of  organisms  of  a  certain  kind  ceases  when  certain  chemical  (?) 
changes  take  place  in  their  environment.  Fermentation  in  a 
saccharine  liquid  ceases  and  the  ferment-organisms  die  when  the 
accumulation  of  the  product  of  the  fermentation  (alcohol)  has 
reached  a  certain  proportion,  although  there  may  still  be  un- 
decomposed  sugar  present.  In  like  manner  it  is  intelligible  that 
the  products  of  micro-organisms  may  eventually  destroy  their 
producers,  and  so  place  a  limit  to  the  morbid  process.  The 
specific  cause  of  small-pox,  yellow  fever,  cholera,  and  similar 
infectious  diseases  is  rapidly  destroyed  when  decomposition  of 
the  corpses  of  those  dead  with  such  diseases  sets  in.  Hence, 
the  reason  why  infectious  diseases  are  not  spread  from  cemeteries. 

From  the  foregoing  it  may  be  gathered  that  disinfection 
consists  chiefly  in  a  struggle  against  organized  disease-germs.1 
As,  however,  experiments  and  observations  have  shown  that  the 
life-history  of  disease-germs  varies  with  the  different  organisms 
involved,  it  becomes  evident  that  specific  directions  concerning 
disinfection  can  be  given  only  when  the  life-history  of  the 
specific  organism  is  known. 

The  American  Committee  on  Disinfectants,  to  whose  work 
reference  has  already  been  made,  divides  disinfectants  into  two 
classes :  those  efficient  for  the  destruction  of  infectious  material 
containing  spores,  and  those  which  will  destroy  infectious  ma- 
terial only  in  the  absence  of  spores.  The  recommendations  of 

i  Mueller  und  Falk,  in  Realencyclopaedie  d.  ges.  Heilk.,  Bd.  IV.,  p.  62. 


390  TEXT-BOOK   OF   HYGIENE. 

the  committee,  covering  not  only  the  appropriate  disinfectant  to 
be  used  for  the  destruction  of  the  organisms,  but  also  the  con- 
ditions under  which  the  agent  should  be  used,  are  as  follow : — 

The  most  useful  agents  for  the  destruction  of  spore-containing 
infectious  material  are  : — 

1.  Fire.     Complete  destruction  by  burning. 

2.  Steam  under  pressure.     105°  C.  (221°  F.)  for  ten  minutes. 

3.  Boiling  in  water  for  half  an  hour. 

4.  Chlorinated  lime.'1     A  4-per-cent.  solution. 

5.  Mercuric  chloride.     A  solution  of  1  to  500. 

For  the  destruction  of  infectious  material  which  owes  its  infecting 
power  to  the  presence  of  micro-organisms  not  containing  spores,  the 
committee  recommends  : — 

1.  Fire.  Complete  destruction  by  burning. 

2.  Boiling  in  water  for  ten  minutes. 

3.  Dry  heat.     110°  C.  (230°  F.)  for  two  hours. 

4.  Chlorinated  lime.1     A  2-per-cent.  solution. 

5.  Solution  of  chlorinated  soda.2     A  10-per-cent.  solution. 

6.  Mercuric  chloride.     A  solution  of  1  to  2000. 

7.  Sulphur  dioxide.     Exposure  for  twelve  hours  to  an  atmosphere 
containing   at   least  4  volumes   per  cent,   of  this   gas    in  presence  of 
moisture.3 

8.  Carbolic  acid.     A  5-per-cent.  solution. 

9.  Sulphate  of  copper.     A  5-per-cent.  solution. 
10.   Chloride  of  zinc.     A  10-per-cent.  solution. 

The  committee  would  make  the  following  recommendations  with 
reference  to  the  practical  application  of  these  agents  for  disinfecting 
purposes : — 

FOR  EXCRETA. 

(a)  In  the  sick-room  : — 

1.  Chlorinated  lime  in  solution,  4  percent. 
In  the  absence  of  spores  : — 

2.  Carbolic  acid  in  solution,  5  per  cent. 

3.  Sulphate  of  copper  in  solution,  5  per  cent. 
(6)  In  privy-vaults  : — 

1.  Mercuric  chloride  in  solution,  1  to  500. 4 

2.  Carbolic  acid  in  solution,  5  per  cent. 

1  Should  contain  at  least  25  per  cent,  of  available  chlorine. 

9  Should  contain  at  least  3  per  cent,  of  available  chlorine. 

1  This  will  require  the  combustion  of  between  1%  to  2  kilogrammes  of  sulphur  for  every 
28  cubic  metres  of  air-space.  The  vaporization  of  liquid  sulphur-dioxide  can  be  more  accurately 
regulated. 

4  The  addition  of  an  equal  quantity  of  potassium  permanganate  as  a  deodorant,  and  to 
give  color  to  the  solution,  is  to  be  recommended. 


ANTISEPTICS,    DISINFECTANTS,    AND    DEODORANTS.  391 

(c)  For  the  disinfection  and  deodorization  of  the  surface  of  masses 
of  organic  material  in  privy-vaults  etc.: — 
Chlorinated  lime  in  powder. 

FOR  CLOTHING,  BEDDING,  ETC. 

(a)  Soiled  underclothing,  bed-linen,  etc.: — 

1.  Destruction  by  fire,  if  of  little  value. 

2.  Boiling  for  at  least  half  an  hour. 

3.  Immersion  in  a  solution  of  mercuric  chloride  of  the  strength 
of  1  to  2000  for  four  hours. 

4.  Immersion  in  a  2-per-cent.  solution  of  carbolic  acid  for  four  ' 
hours. 

(6)  Outer  garments  of  wool  or  silk,  and  similar  articles,  which 
would  be  injured  by  immersion  in  boiling  water  or  in  a  disinfecting 
solution : — 

1.  Exposure  in  a  suitable  apparatus  to  a  current  of  steam  for 
ten  minutes. 

2.  Exposure  to  dry  heat  at  a  temperature  of  110°  C.  (230°  F.) 
for  two  hours. 

(c)  Mattresses  and  blankets  soiled  by  the  discharges  of  the  sick : — 

1.  Destruction  by  fire. 

2.  Exposure  to  superheated  steam  (105°  C.  =  221°  F.)  for  ten 
minutes.      (Mattresses   to    have   the    cover    removed   or   freely 
opened.) 

3.  Immersion  in  boiling  water  for  half  an  hour. 

FURNITURE  AND.  ARTICLES  OF  WOOD,  LEATHER,  AND  PORCELAIN. 

Washing,  several  times  repeated,  with  solution  of  carbolic  acid,  2 

per  cent. 

FOR  THE  PERSON. 

The  hands  and  general  surface  of  the  body  of  attendants  of  the 
sick,  and  of  the  convalescents,  should  be  washed  with — 

1.  Solution   of   chlorinated    soda   diluted  with   nine   parts  of 
water  (1  to  10). 

2.  Carbolic  acid,  2-per-cent.  solution. 

3.  Mercuric  chloride,  1  to  1000. 

FOR  THE  DEAD. 
Envelop  the  body  in  a  sheet  thoroughly  saturated  with — 

1.  Chlorinated  lime  in  solution,  4  per  cent. 

2.  Mercuric  chloride  in  solution,  1  to  500. 

3.  Carbolic  acid  in  solution,  5  per  cent. 


392  TEXT-BOOK   OF    HYGIENE. 

FOR  THE  SICK-ROOM  AND  HOSPITAL  WARDS. 

(a)  While  occupied,  wash  all  surfaces  with — 

1.  Mercuric  chloride  in  solution,  1  to  1000. 

2.  Carbolic  acid  in  solution,  2  per  cent. 
(6)  When  vacated  : — 

Fumigate  with  sulphur  dioxide  for  twelve  hours,  burning  at  least  1^ 
kilogrammes  sulphur  for  every  28  cubic  metres  of  air-space  in  the  room  ; 
then  wash  all  surfaces  with  one  of  the  above-mentioned  disinfecting 
solutions,  and  afterward  with  soap  and  hot  water ;  finally  throw  open 
doors  and  windows  and  ventilate  freely. 

FOR  MERCHANDISE  AND  THE  MAILS. 

The  disinfection  of  merchandise  and  of  the  mails  will  only  be 
required  under  exceptional  circumstances  ;  free  aeration  will  usually  be 
sufficient.  If  disinfection  seems  necessary,  fumigation  with  sulphur 
dioxide  will  be  the  only  practicable  method  of  accomplishing  it  without 

injury. 

RAGS. 

(a)  Rags  which  have  been  used  for  wiping  away  infectious  discharges 
should  at  once  be  burned. 

(6)  Rags  collected  for  the  paper-makers  during  the  prevalence  of 
an  epidemic  should  be  disinfected,  before  they  are  compressed  in  bales, 

by- 

1.  Exposure  to  superheated  steam  (105°  C.=  221°  F.)  for  ten 
minutes. 

2.  Immersion  in  boiling  water  for  half  an  hour. 

SHIPS. 

(a)  Infected  ships  at  sea  should  be  washed  in  every  accessible  place, 
and  especially  localities  occupied  by  the  sick,  with — 

1.  Solution  of  mercuric  chloride,  1  to  1000. 

2.  Solution  of  carbolic  acid,  2  per  cent. 

The  bilge  should  be  disinfected  by  the  liberal  use  of  a  strong 
solution  of  mercuric  chloride. 

(b)  Upon  arrival  at  a  quarantine  station,  an  infected  ship  should  at 
once  be  fumigated  with  sulphurous-acid  gas,  using  1^  kilogi-ammes  of 
sulphur  for  every  28  cubic  metres   of  air-space ;  the  cargo  should  then 
be  discharged  on  lighters  ;  a  liberal  supply  of  the  concentrated  solution 
of  mercuric  chloride  (1  to  32)  should  be  thrown  into  the  bilge,  and  at  the 
end  of  twenty-four  hours  the  bilge-water  should  be  pumped  out  and 
replaced  with  pure  sea-water ;  this  should  be  repeated.     A  second  fumi- 
gation after  the  removal  of  the  cargo  is  recommended.     All  accessible 


ANTISEPTICS,    DISINFECTANTS,    AND    DEODORANTS.  393 

surfaces  should  be  washed  with  one  of  the  disinfecting  solutions  here- 
tofore recommended^  and  subsequently  with  soap  and  hot  water. 

FOR  RAILWAY-CARS. 

The  directions  given  for  the  disinfection  of  dwellings,  hospital 
wards,  and  ships  apply  as  .well  to  infected  railway-cars.  The  treatment 
of  excreta  with  a  disinfectant  before  they  are  scattered  along  the  tracks 
seems  desirable  at  all  times,  in  view  of  the  fact  that  they  may  contain 
infectious  germs.  During  the  prevalence  of  an  epidemic  of  cholera  this 
is  imperative.  For  this  purpose  the  standard  solution  of  chlorinated 
lime  is  recommended. 

From  the  foregoing  it  would  appear  that  heat,  chlorinated 
lime,  mercuric  chloride,  solution  of  chlorinated  soda  (Labar- 
raque's  solution),  carbolic  acid,  sulphate  of  copper,  zinc  chloride, 
and  sulphur  dioxide  (sulphur -fumes)  are  the  most  generally 
available  disinfectants. 

The  following  "  general  directions  "  for  the  practical  appli- 
cation of  disinfection  are  given  by  the  committee : — 

Disinfection  of  Excreta,  etc. — The  infectious  character  of  the  dejec- 
tions of  patients  suffering  from  cholera  and  ttyphoid  fever  is  well  estab- 
lished ;  and  this  is  true  of  mild  cases  and  of  the  earliest  stages  of  these 
diseases,  as  well  as  of  severe  and  fatal  cases.  It  is  probable  that  epidemic 
dysentery,  tuberculosis,  and  perhaps  diphtheria,  yellow  fever,  scarlet 
fever,  and  t}rphus  fever  ma}"  also  be  transmitted  by  means  of  the  alvine 
discharges  of  the  sick.  It  is,  therefore,  of  the  first  importance  that  these 
should  be  disinfected.  In  cholera,  diphtheria,  }-ellow  fever,  and  scarlet 
fever  all  vomited  material  should  also  be  looked  upon  as  infectious. 
And  in  tuberculosis,  diphtheria,  scarlet  fever,  and  infectious  pneumonia 
the  sputa  of  the  sick  should  be  disinfected  or  destroyed  by  fire.  It  seems 
advisable,  also,  to  treat  the  urine  of  patients  sick  with  an  infectious 
disease  with  one  of  the  disinfecting  solutions  below  recommended. 

Chloride  of  lime,  or  bleaching  powder,  is  perhaps  entitled  to  the  first 
place  for  disinfecting  excreta,  on  account  of  the  rapidity  of  its  action. 
The  following  standard  solution  is  recommended  : — 

Dissolve  chloride  of  lime  (chlorinated  lime,  bleaching  powder)  of  the 
best  quality1  in  pure  water  in  the  proportion  of  6  ounces  to  the  gallon 
(45  grammes  to  the  litre). 

Use  1  quart  (1  litre)  of  this  solution  for  the  disinfection  of  each  dis- 
charge in  cholera,  typhoid  fever,  etc.3  Mix  well,  and  leave  in  the  vessel 

1  Good  chloride  of  lime  should  contain  at  least  25  per  cent,  of  available  chlorine. 
Recently  nascent  chlorine  for  disinfecting  purposes  has  been  obtained  on  a  large  scale  by  the 
electrolysis  of  sea-water. 

3  For  a  very  copious  discharge  use  a  larger  quantity. 


394  TEXT-BOOK   OF   HYGIENE. 

for  at  least  one  hour  before  throwing  into  priv}r-well  or  water-closet. 
The  same  directions  appty  for  the  disinfection  of  vomited  matters. 
Infected  sputum  should  be  discharged  directly  into  a  cup  half  full  of  the 
solution.1  A  5-per-cent.  solution  of  carbolic  acid  may  be  used  instead 
of  the  chloride-of-lime  solution,  the  time  of  exposure  to  the  action  of  the 
disinfectant  being  four  hours. 

Disinfection  of  the  Person. — The  surface  of  the  body  of  a  sick  person 
or  of  his  attendants,  when  soiled  with  infectious  discharges,  should  be  at 
once  cleansed  with  a  suitable  disinfecting  agent.  For  this  purpose,  solu- 
tion of  chlorinated  soda  (liquor  sodse  chlorinatse — Labarraque's  solution) 
diluted  with  9  parts  of  water,  or  the  standard  solution  of  chloride  of  lime 
diluted  with  3  parts  of  water,  may  be  used.  A  2-per-cent.  solution  of 
carbolic  acid  is  also  suitable  for  this  purpose,  and  under  proper  medical 
supervision  the  use  of  a  solution  of  corrosive  sublimate  (1  to  1000)  is  to 
be  recommended. 

In  diseases  like  small-pox  and  scarlet  fever,  in  which  the  infectious 
agent  is  given  off  from  the  entire  surface  of  the  body,  occasional  ablu- 
tions with  the  above-mentioned  solution  of  chlorinated  soda  are  recom- 
mended. 

In  all  infectious  diseases  the  body  of  the  dead  should  be  enveloped 
in  a  sheet  saturated  with  the  standard  solution  of  chlorinated  lime,  or 
with  a  5-per-cent.  solution  of  carbolic  acid,  or  a  1  to  500  solution  of  cor- 
rosive sublimate. 

Disinfection  of  Clothing. — Boiling  for  half  an  hour  will  destroy  the 
vitality  of  all  known  disease-germs,  and  there  is  no  better  way  of  dis- 
infecting clothing  or  bedding  which  can  be  washed  than  to  put  it 
through  the  ordinary  operations  of  the  laundry.  No  delay  should  occur, 
however,  between  the  time  of  removing  soiled  clothing  from  the  person 
or  bed  of  the  sick  and  its  immersion  in  boiling  water,  or  in  one  of  the 
following  solutions  until  this  can  be  done : — 

Corrosive  sublimate,  1  gramme  to  the  litre  (1  to  1000),  or  carbolic 
acid  (pure),  8  grammes  to  the  litre. 

The  articles  to  be  disinfected  must  be  thoroughly  soaked  with  the 
disinfecting  solution  and  left  in  it  for  at  least  two  hours,  after  which  they 
may  be  wrung  out  and  sent  to  the  wash.2 

Clothing  or  bedding  which  cannot  be  washed  should  be  disinfected 

1  Recently  a  small  spitting-cup  made  of  stiff  paper  has  been  introduced  especially  for  the 
use  of  consumptives.  The  cup  is  carried  about  by  the  patient  or  kept  within  reach.  When  the 
cup  has  been  in  use  for  a  time,  and  before  the  sputa  can  become  desiccated,  it  is  thrown  into  the 
fire  and  burned. 

*  Solutions  of  corrosive  sublimate  should  not  be  placed  in  metal  receptacles,  for  the  salt  is 
decomposed  and  the  mercury  precipitated  by  contact  with  copper,  lead,  or  tin.  A  wooden  tub 
or  earthen  crock  is  a  suitable  receptacle  for  such  solutions. 


ANTISEPTICS,    DISINFECTANTS,    AND    DEODORANTS.  395 

by  steam  in  a  properly-constructed  disinfection  chamber.  In  the  absence 
of  a  suitable  steam  disinfecting  apparatus,  infected  clothing  and  bedding 
should  be  burned. 

Disinfection  of  the  Sick-room. — In  the  sick-room  no  disinfectant  can 
take  the  place  of  free  ventilation  and  cleanliness.  It  is  an  axiom  in  sani- 
tary science  that  it  is  impracticable  to  disinfect  an  occupied  apartment 
for  the  reason  that  disease-germs  are  not  destroyed  by  the  presence  in 
the  atmosphere  of  any  known  disinfectant  in  respirable  quantity.  Bad 
odors  may  be  neutralized,  but  this  does  not  constitute  disinfection  in  the 
sense  in  which  the  term  is  here  used.  These  bad  odors  are,  for  the  most 
part,  an  indication  of  want  of  cleanliness  or  of  proper  ventilation,  and  it 
is  better  to  turn  contaminated  air  out  of  the  window  or  up  the  chimney 
than  to  attempt  to  purify  it  by  the  use  of  volatile  chemical  agents,  such 
as  carbolic  acid,  chlorine,  etc.,  which  are  all  more  or  less  offensive  to  the 
sick,  and  are  useless  so  far  as  disinfection — properly  so  called — is  con- 
cerned. 

When  an  apartment  which  has  been  occupied  by  a  person  sick  with 
an  infectious  disease  has  been  vacated,  it  should  be  disinfected.  The 
object  of  disinfection  in  the  sick-room  is  mainly  the  destruction  of  infec- 
tious material  attached  to  surfaces  or  deposited  as  dust  upon  window- 
ledges,  in  crevices,  etc.  If  the  room  has  been  properly  cleansed  and 
ventilated  while  still  occupied  by  the  sick  person,  and  especially  if  it 
was  stripped  of  carpets  and  unnecessar}r  furniture  at  the  outset  of  his 
attack,  the  difficulties  of  disinfection  will  be  greatly  reduced. 

All  surfaces  should  be  thoroughly  washed  with  the  standard  solu- 
tion of  chloride  of  lime,  diluted  with  3  parts  of  water,  or  with  >1  to  1000 
solution  of  corrosive  sublimate.  The  walls  and  ceiling,  if  plastered, 
should  be  subsequently  treated  with  a  lime-wash.  Especial  care  must 
be  taken  to  wash  away  all  dust  from  window-ledges  and  other  places 
where  it  may  have  settled,  and  thoroughly  to  cleanse  crevices  and  out- 
of-the-way  places.  After  this  application  of  the  disinfecting  solution, 
and  an  interval  of  twenty-four  hours  or  longer  for  free  ventilation,  the 
floors  and  wood-work  should  be  well  scrubbed  with  soap  and  hot  water, 
and  this  should  be  followed  by  a  second,  more  prolonged  exposure  to 
fresh  air,  admitted  through  open  doors  and  windows. 

As  an  additional  precaution,  fumigation  with  sulphurous-acid  gas  is 
to  be  recommended,  especially  for  rooms  which  have  been  occupied  by 
patients  with  small-pox,  scarlet  fever,  diphtheria,  typhus  fever  and  yel- 
low fever.  But  fumigation  with  sulphurous-acid  gas  alone,  as  commonly 
practiced,  cannot  be  relied  upon  for  disinfection  of  the  sick-room  and  its 
contents,  including  bedding,  furniture,  infected  clothing,  etc.,  as  is  popu- 
larly believed. 


396  TEXT-BOOK    OF    HYGIENE. 

When  fumigation  is  practiced,  it  should  precede  the  general  washing 
with  a  disinfecting  solution  heretofore  recommended.  To  insure  any 
results  of  value,  it  will  be  necessary  to  close  the  apartment  to  be  disin- 
fected as  completely  as  possible  by  stopping  up  all  apertures  through 
which  the  gas  might  escape,  and  to  burn  not  less  than  3  pounds  of 
sulphur  for  each  1000  cubic  feet  (1^  kilogrammes  to  28  cubic  metres)  of 
air-space  in  the  room.  To  secure  complete  combustion  of  the  sulphur, 
it  should  be  placed,  in  the  form  of  powder  or  small  fragments,  into  a 
shallow  iron  pan,  which  should  be  set  upon  a  couple  of  bricks  in  a  tub 
partly  filled  with  water,  to  guard  against  fire.  The  sulphur  should  be 
thoroughly  moistened  with  alcohol  before  igniting  it.1 

Disinfection  of  Privy-vaults,  Cess-pools,  etc. — When  the  excreta 
(not  previously  disinfected)  of  patients  with  cholera  or  typhoid  fever 
have  been  thrown  into  a  privy-vault  this  is  infected,  and  disinfection 
should  be  resorted  to  as  soon  as  the  fact  is  discovered,  or  whenever  there 
is  reasonable  suspicion  that  such  is  the  case.  It  will  be  advisable  to  take 
the  same  precautions  with  reference  to  privy-vaults  into  which  the  ex- 
creta of  yellow  fever  have  been  thrown,  although  we  do  not  definitely 
know  that  this  is  infectious  material. 

For  this  purpose  the  standard  solution  of  chloride  of  lime  may  be 
used  in  quantity  proportioned  to  the  amount  of  material  to  be  disin- 
fected, but  where  this  is  considerable  it  will  scarcely  be  practicable  to 
sterilize  the  whole  mass.  The  liberal  and  repeated  use  of  this  solution, 
or  of  a  5-per-cent.  solution  of  carbolic  acid,  will,  however,  disinfect  the 
surface  of  the  mass,  and  is  especially  to  be  recommended  during  the  epi- 
demic prevalence  of  typhoid  fever  or  of  cholera. 

All  exposed  portions  of  the  vault,  and  the  wood-work  above  it, 
should  be  thoroughly  washed  down  with  the  disinfecting  solution.  In- 
stead of  the  disinfecting  solutions  recommended,  chloride  of  lime  in 
powder  may  be  daity  scattered  over  the  contents  of  the  privy- vault. 

Disinfection  of  Ingesta. — It  is  well  established  that  cholera  and 
typhoid  fever  are  very  frequently,  and  perhaps,  usually,  transmitted 
through  the  medium  of  infected  water  or  articles  of  food,  and  especially 
milk.  Fortunately,  we  have  a  simple  means  at  hand  for  disinfecting  such 
infected  fluid.  This  consists  in  the  application  of  heat.  The  boiling 
temperature  maintained  for  half  an  hour  kills  all  known  disease-germs. 
So  far  as  the  germs  of  cholera,  }'ellow  fever,  and  diphtheria  are  concerned, 
there  is  good  reason  to  believe  that  a  temperature  considerably  below 
the  boiling-point  of  water  will  destroy  them.  But  in  order  to  keep  on 
the  safe  side,  it  is  best  not  to  trust  anything  short  of  the  boiling-point 
(100°  C.  =  212°  F.)  when  the  object  is  to  disinfect  food  or  drink  which  is 

1  Liquid  anhydrous  sulphur-dioxide  may  be  used,  and  will  probably  give  better  results 
than  combustion  of  sulphur. 


ANTISEPTICS,   DISINFECTANTS,  AND  DEODORANTS.  397 

open  to  the  suspicion  of  containing  the  germs  of  an}'  infectious  disease. 
During  the  prevalence  of  an  epidemic  of  cholera  it  is  well  to  boil  all  water 
for  drinking  purposes.  After  boiling,  the  water  may  be  filtered,  if  neces- 
sary, to  remove  sediment,  and  then  cooled  with  pure  ice  if  desired. 

The   following    substances    are    antiseptics,   but    in    the 
strength  given  cannot  be  depended  upon  as  disinfectants : — 

TABLE  XXXI. 

Thymol, 1:80,000. 

Bichloride  of  mercury, 1 : 40,000. 

Oil  of  mustard, 1  : 33,000. 

Acetate  of  alumina, 1  :  6310. 

Bromine,         .         .         .         .         .         .         .         .     1:5597. 

Picric  acid, 1:5000. 

Iodine, 1:4000. 

Sulphuric  acid, 1:800-1:3353. 

Permanganate  of  potassium,          .         .         .         .     1  : 3000. 

Camphor, 1:2500. 

Eucalyptol, .     1:2500. 

Chromic  acid, .     1:2200. 

Chloride  of  aluminum, 1  : 2000. 

Hydrochloric  acid, 1  '•  1700. 

Benzoic  acid,          .         .         .        .        .         .         .     1 : 1439. 

Quinine,          .         .         .         .        .         .         •         -Is  1000. 

Boric  acid,     '. 1:200-1:800. 

Salicylic  acid,         .         .         .        .         .         .1:200-1:800. 

Carbolic  acid, 1:500. 

Sulphate  of  copper, 1 : 40°- 

Nitric  acid, 1:400. 

Biborate  of  soda, 1 : 200. 

Sulphate  of  iron, 1 : 2°°- 

Creasote, 1:200. 

Arsenious  acid, 1 :  100- 

Pyrogallic  acid, •     •         .     1 : 62. 

Tr.  chloride  of  iron, 1 : 25. 

Alcohol,          .        .        .        •        •        .     40  to  95  per  cent. 

The  agents  mentioned  in  the  above  list  may  all  be  used 
with  satisfactory  results  in  surgical  and  obstetrical  practice  as 
antiseptics,  but  it  must  be  borne  in  mind  that  the  great  danger 
in  treating  wounds  comes  from  carrying  infectious  particles  to 
them  in  the  hands  or  instruments  of  the  operator.  In  order  to 


398  TEXT-BOOK   OF    HYGIENE. 

render  these  aseptic  the  most  thorough  measures  of  disinfection, 
such  as  heat,  strong  chemical  disinfectants,  and  physical  as  well 
as  chemical  and  biological  cleanliness  are  indicated.  In  a  sur- 
gical wound,  or  in  the  vagina  and  uterus  of  the  parturient 
woman,  the  use  of  antiseptics  is  entirely  secondary  to  disinfec- 
tion, under  which  may  primarily  be  understood  rigid  cleanliness. 

In  public  and  private  sanitation,  antiseptics  have,  as  in 
practical  surgery,  a  subordinate  importance. 

Deodorizers  are  sometimes  useful  in  sanitary  practice,  but 
care  must  be  taken  not  to  look  upon  deodorization  as  equiva- 
lent to  disinfection.  Among  the  most  useful  deodorizers  are 
chloride  of  zinc,  chloride  of  lime,  permanganate  of  potassium, 
and  a  number  of  the  agents  mentioned  in  Table  XXXI. 

[The  following  additional  works  are  recommended  for 
study  in  connection  with  this  chapter : — 

Sternberg  and  Magnin,  The  Bacteria,  2d  ed. — Fluegge,  Fermente 
und  Mikroparasiten,  in  von  Pettenkofer  und  Ziemssen's  Handb.  d. 
Hygiene,  I  Th.,  2  Abth.,  1  Hft. — Wernich,  Desinfectionslehre  zum  prak- 
tischen  Gebrauch. — Tallin,  Traite  des  Disinfectants  etde  la  Disinfection. 
— Final  Report  of  the  Committee  on  Disinfectants  of  the  American 
Public  Health  Association. — Sternberg,  Disinfection  and  Personal 
Prophylaxis  Lomb  Prize  Essay.  1886.] 


QUESTIONS   TO   CHAPTER  XX. 

ANTISEPTICS,  DISINFECTANTS,  AND  DEODORANTS. 

What  is  an  antiseptic  ?  How  may  it  be  used  ?  Is  it  necessarily  a 
disinfectant  ?  Why  ?  Is  a  disinfectant  an  antiseptic  ?  Why  ?  Why 
must  disinfection  be  thorough  to  be  of  any  value  ?  What  is  necessary 
that  there  may  be  disinfection  ?  How  is  the  term  often  popularty,  but  in- 
rcorrectly,  used  ? 

What  is  the  essential  difference  between  a  disinfectant  and  a  de- 
odonint  ?  What  is  a  germicide  ?  What  is  the  true  test  of  the  value  of  a 
disinfectant  ?  Have  deodorants  as  such  any  real  sanitary  value  ?  How 
do  disinfectants  differ  in  relation  to  disease-germs  ?  How  do  the  latter 
differ  in  relation  to  the  former  ?  How  may  the  products  of  putrefaction, 
fermentation,  or  decay  act  as  disinfectants?  How  may  the  products  of 
the  disease-germs  themselves  act  as  antiseptics  or  disinfectants? 

How  may  disinfectants  be  classified?  What  are  most  useful  agents 
for  destroying  spore-containing  infectious  material?  How  should  these 
be  used  ?  What  do  we  call  disinfection  by  fire  or  heat  ?  What  agents 
may  be  used  to  disinfect  infectious  matter  not  continuing  spores  ?  Which 
are  most  efficacious  ?  What  is  an  essential  factor  in  the  successful  use 
of  all  disinfectants  ? 

In  what  diseases  may  the  excreta  be  infected  ?  What  disinfectants 
may  be  used  for  excreta  in  the  sick-room  ?  In  cess-pools  ?  Why  is 
mercuric  chloride  not  so  efficacious  here?  What  is  the  objection  to  the 
use  of  carbolic  acid  in  typhoid  fever?  Why  is  chlorinated  lime  such  a 
valuable  disinfectant  ?  How  much  chlorine  should  it  contain  ?  How 
should  it  be  prepared  ?  What  is  "  milk  of  lime,"  and  what  value  has  it 
as  a  disinfectant  for  excreta  ? 

How  may  soiled  underclothing,  bed-linen,  etc.,  be  disinfected  ?  How 
long  should  clothing  be  boiled  in  order  to  thoroughly  disinfect  it?  How 
may  clothing  that  would  be  harmed  by  immersion  or  chemicals  be  dis- 
infected ?  What  will  be  the  effects  on  clothing  of  chlorine  and  sulphur 
gases?  How  may  mattresses,  blankets,  etc.,  be  disinfected ?  How  long 
should  the  active  process  require  ? 

(399) 


400  QUESTIONS   TO   CHAPTER   XX. 

What  are  some  of  the  best  disinfectants  for  use  on  the  person  ?  How 
may  the  danger  of  infection  from  a  case  of  scarlet  fever,  small-pox,  etc., 
be  lessened  ?  How  should  the  bodies  of  those  dead  of  infectious  dis- 
eases be  cared  for  ? 

What  can  be  done  in  the  way  of  disinfection  during  the  occupancy 
of  the  sick-room  ?  What  are  the  only  disinfectants  available  ?  What 
value  will  deodorants  have  here  ?  What  method  is  to  be  followed  as  soon 
as  the  sick-room  is  vacated  ?  Describe  in  detail. 

How  may  suspected  merchandise  and  the  mails  be  purified  ?  What 
treatment  should  rags,  etc.,  undergo?  What  is  the  method  prescribed 
for  the  disinfection  of  a  ship?  For  railway -cars  ?  (See  chapter  on 
Quarantine.) 

How  may  articles  of  food  and  drink  be  made  sterile  and  safe  for  use  ? 

How  are  antiseptics  and  disinfectants  to  be  used,  and  for  what  pur- 
pose, in  surgical  and  obstetrical  practice  ? 


CHAPTER   XXL 

VITAL  STATISTICS. 

(Revised  by  SENECA  EGBERT,  A.M.,  M.D.) 

THE  registration  of  vital  statistics  comprises  the  recording 
of  the  births,  marriages,  deaths,  and  diseases  of  a  city,  State,  or 
nation.  The  facts  thus  secured  must  be  properly  classified  and 
studied,  for  in  no  other  way  can  a  knowledge  of  the  health  of 
the  inhabitants  of  such  communities  be  obtained,  and  a  real 
test  is  thus  also  furnished  of  the  actual  efficiency  of  sanitary 
undertakings.  We  may,  indeed,  study  disease  both  by  observa- 
tion and  experiment,  thus  learning  that  some  maladies  are  more 
preventable  than  others  and  discovering  their  causes  and  means 
of  prevention ;  and  it  is  also  true  that  for  smaller  or  special 
communities,  such  as  armies,  navies,  schools,  or  special  classes 
of  workmen,  the  health  status  may  be  obtained  by  direct 
methods ;  but  for  large  communities  this  is  clearly  impracti- 
cable, and  the  sanitarian  is  obliged  to  depend  upon  the  census 
and  the  above-mentioned  registration. 

The  census  is  the  count  of  its  population  which  every 
civilized  country  makes  at  certain  intervals,  its  returns  also 
including  particulars  as  to  age,  sex,  race,  occupation,  etc. 
From  the  sanitarian's  stand-point  the  age-record  is,  next  to  the 
population,  the  most  important  return,  for  the  death-rate  varies 
most  according  to  age.  In  this  country  the  census  now  fur- 
nishes various  data  for  localized  "  sanitary  districts,"  which  may 
be  even  smaller  than  city  wards,  and  these  data  afford  the  basis 
of  comparison  for  variations  in  different  parts  of  the  same  city 
and  at  different  periods. 

The  records  of  births,  marriages,  deaths,  and  diseases  are 
obtained  from  the  registration  bureau,  having  been  furnished 
the  latter  by  duly  authorized  persons.  The  duty  of  registration 
should  devolve  upon  the  sanitary  administration,  such  as  the 

26  (401) 


402  TEXT-BOOK    OP   HYGIENE. 

local  or  State  board  of  health,  this  being  the  most  appropriate 
medium  for  the  collection  of  the  information  in  question,  while 
the  individual  returns  should  obviously  be  made  to  the  bureau 
by  the  attending  physician  in  each  case.  And,  as  these  returns 
should  be  as  accurate  as  possible,  especially  as  regards  the  diag- 
nosis of  preventable  diseases  and  the  determination  of  the  causes 
of  death,  both  primary  and  secondary,  it  is  one  of  the  reasons 
why  the  State  should  carefully  determine  the  qualifications  of 
the  physicians  whom  it  allows  to  practice  within  its  confines. 

From  a  sanitary  point  of  view,  the  most  important  object  of 
a  registration  of  vital  statistics  is  to  "  give  warning  of  the  undue 
increase  of  disease  or  death  presumed  to  be  due  to  preventable 
causes,  and  to  indicate  the  localities  in  which  sanitary  effort  is 
most  desirable  and  most  likely  to  be  of  use."1 

It  should  be  remembered  that  the  following  fundamental 
principles  that  underlie  all  statistical  inquiries  must  be  consid- 
ered in  the  examination  and  analysis  of  any  records  or  reports 
of  the  kind  in  question  : — 

1.  The  numerical  units  with  which  the  inquiry  has  to  do 
must  be  constant,  definite,  and  precise  in  character ;  if  any  lack 
these  qualities,  such  should  be  omitted  altogether.     Hence  the 
care  that  should  be  observed  in  the  diagnosis  of  all  cases. 

2.  Groups  of  the  numerical   units  must  be   so  arranged 
that  no  unit  is  in  more  than  one  group  at  a  time,  and  so  that 
there  can  be  no  question  as  to  the  group  in  which  each  unit 
belongs.     This   is  comparatively  simple    where    the   grouping 
regards  only  the  age,  sex,  race,  etc.,  but  the  difficulty  increases 
with  the  complexity  of  facts   and   requires    special   talent    to 
properly  analyze  and  develop  all  possible  features. 

3.  There  must  be  a  standard  to  express  the  relation  of 
each  group  to  the  sum  of  the  individual  unit.     This  is  usually 
100,  1000,  or  some  multiple  of  either. 

4.  The  relation  of  each  group  to  the  total  units  is  not  a 

1  J.  S.  Billings,  "  Registration  of  Vital  Statistics,"  American  Journal  of  the  Medical  Sci- 
ences, vol.  Ixxxv,  p.  37. 


VITAL    STATISTICS.  403 

constant  one  unless  all  the  factors  which  govern  that  relation 
are  fixed  and  invariable, — a  condition  which  obviously  does 
not  obtain  in  vital  statistics.  The  limit  of  variation  in  the 
relation  of  the  component  groups  to  the  total,  in  two  or  more 
similar  series,  may,  however,  be  expressed  mathematically,  and 
the  variation  itself  will  be  found  to  diminish  as  the  sum  of  in- 
dividual units  increases.  Thus,  if,  in  the  formula  m  -f-  n  —  q, 
m  be  the  number  of  units  in  one  group  and  n  the  number  in 
the  other,  the  limit  of  variation  will  be  indicated  by  the  expres- 
sion 2-s/?^1;  or,  again,  the  relative  value  of  two  or  more  series 
is  as  the  square  roots  of  the  number  of  units  in  the  respective 
series. 

The  arithmetical  mean  is  often  used  in  vital  statistics,  and 
this  will  always  approximate  the  invariable  if  the  number  of 
units  is  sufficient,  but  it  must  be  remembered  that  the  relation 
expressed  by  the  average  in  one  case  cannot  be  predicated  posi- 
tively of  any  other.  As  Dr.  Guy  says,  "  Averages  are  numerical 
expressions  of  probabilities ;  extreme  values  are  expressions  of 
possibilities." 

The  graphic  representation  of  statistical  results,  examples 
of  which  are  given  on  pages  21  to  25  of  this  volume,  is  of 
advantage,  since  it  brings  their  salient  features  clearly  before 
the  attention  of  the  observer. 

The  numerical  units  with  which  we  are  concerned  in  vital 
statistics  are  persons,  either  living  or  dead,  and  these  are  di- 
vided into  groups  according  to  age,  sex,  race,  etc.  Populations 
tend  naturally  to  increase,  the  natural  increment  being  meas- 
ured by  the  difference  in  the  number  of  births  and  deaths ;  but 
the  actual  increment  depends  upon  how  this  is  modified  by  the 
relation  between  immigration  and  emigration.  If  these  factors 
were  all  constant,  the  population  would  increase  in  geometrical 
progression ;  but  as  this  is  not  so,  it  cannot  be  exactly  deter- 
mined for  periods  other  than  those  in  which  the  census  is 
taken.  However,  in  determining  the  population  for  years  other 
than  census  years,  it  is  customary  to  assume  that  the  same  rate 


404  TEXT-BOOK   OF   HYGIENE. 

of  increase  continues  as  prevailed  between  the  last  two  cen- 
suses, and  to  calculate  the  population  therefrom  by  means  of 
geometrical  progression  or  logarithms.  The  number  of  houses 
in  a  city  will  help  to  determine  the  approximate  population,  for 
the  average  number  of  persons  to  the  house  in  any  city  remains 
about  the  same  from  year  to  year.  Such  counts,  as  well  as 
police  censuses,  are,  however,  almost  always  too  high.  In 
small  and  slowly-growing  districts  one-tenth  of  the  difference 
in  population  of  the  last  two  censuses  may  be  taken  for  each 
year  since  the  last  census.  The  population  is  always  counted 
and  annual  birth-  and  death-  rates  calculated  for  the  middle  of 
the  year  in  this  country. 

REGISTRATION   OF   BIRTHS. 

The  collection  of  data  for  an  accurate  registration  of  births 
is  much  more  difficult  than  the  record  of  deaths.  Instead  of 
requiring  physicians  and  midwives  in  attendance  at  the  confine- 
ment to  report  births,  it  would  be  more  equitable  and  probably 
more  effectual  to  compel  the  parents,  under  penalty  for  failure, 
to  record  the  birth  of  each  child  at  the  board  of  health.  The 
items  usually  included  in  birth  returns  are :  date  and  place  of 
birth,  sex  and  color  of  child,  names  of  father  and  mother, 
parents'  nativity  and  age,  and  father's  occupation.  Sometimes 
the  residence  of  the  mother,  number  of  children  previously 
borne  by  the  same  mother,  whether  the  child  is  legitimate  or 
not,  and  various  other  details  are  also  added.  It  is  evident  that 
for  sanitary  purposes  most  of  this  information  is  entirely  irrele- 
vant. It  seems  to  the  author  that,  for  the  purpose  of  the  sani- 
tarian and  medical  statistician,  the  date  and  place  of  birth,  sex 
and  color  of  the  child,  and  age,  nativity,  and  occupation  of  both 
parents  are  sufficient. 

REGISTRATION    OF    MARRIAGES. 

The  record  of  marriages  is  of  -no  interest  to  the  sanitarian. 
If,  however,  the  registration  could  be  made  by  a  competent 


REGISTRATION   OF   DEATHS.  405 

medical  man,  and  the  physical  condition  of  the  contracting 
parties  noted,  valuable  deductions  might  be  made  in  time,  espe- 
cially if  the  parties  themselves  and  their  offspring  could  be  kept 
under  observation  for  many  years.  This,  however,  is  so  mani- 
festly impracticable  that  it  barely  deserves  notice  in  this  place. 

REGISTRATION    OF   DISEASES. 

As  has  been  seen  in  Chapter  XIX,  a  large  class  of  diseases 
are  communicable  from  one  individual  to  another,  either  di- 
rectly, by  contact,  or  mediately,  by  infection.  In  large  com- 
munities it  is  therefore  important  that  the  sanitary  authorities 
should  possess  information  of  the  presence  and  prevalence  of 
these  diseases,  in  order  that  measures  may  be  instituted  for  their 
restriction.  It  is  true  that  in  most  cases  the  registration  of 
deaths  gives  but  too  mournful  evidence  of  the  more  fatal  of  the 
diseases  of  this  class,  but  destructive  epidemics  could  probably 
be  frequently  averted  if  preventive  measures  could  be  enforced 
early.  Besides,  in  the  case  of  dengue  and  epidemic  influenza 
the  death-rate  may  be  so  small  that,  if  the  registration  of  deaths 
were  alone  depended  upon,  no  evidence  whatever  might  be  at- 
tainable of  the  epidemic  prevalence  of  such  diseases. 

The  registration  of  prevailing  diseases  is,  therefore,  one  of 
the  most  important  duties  of  the  registrar  of  vital  statistics. 
Prompt  notice  of  all  cases  of  infectious,  miasmatic,  or  contagious 
diseases  coming  under  their  professional  notice  should  be  re- 
quired of  all  physicians.  It  is  unquestionably  just,  however, 
that  the  physicians  required  to  perform  this  duty  should  be 
properly  compensated  by  the  public,  whose  interests  they  serve. 

REGISTRATION   OF    DEATHS. 

The  data  entered  upon  the  record  of  death  should  comprise 
the  name,  age,  sex,  color,  nativity,  descent,  occupation,  and  civil 
condition  of  decedent,  with  date,  place,  and  cause  of  death. 
Under  the  heading  "  Descent "  the  birthplace  of  each  parent 
should  be  given.  Occupation  should  be  accurately  specified. 


406  TEXT-BOOK   OP   HYGIENE. 

The  place  of  death  should  indicate  the  exact  locality  (number 
of  street)  where  it  occurred.  Both  proximate  and  predisposing 
causes  of  death  should  be  entered,  and  any  complications  which 
may  have  influenced  the  fatal  termination  should  be  noted  on 
the  record. 

This  record  should  be  in  the  possession  of  the  local  health 
authority  before  a  permit  for  the  burial  of  the  deceased  is 
granted.  If  this  is  not  insisted  upon,  the  report  will  soon  be 
omitted  and  the  registration  become  defective.  In  fact,  any 
system  that  puts  off  the  collecting  and  recording  of  the  death 
returns  till  the  end  of  the  year  will  fail  to  register  from  25  to  40 
per  cent,  of  the  number. 

DEATH-RATE  AND   BIRTH-RATE. 

In  order  to  calculate  the  annual  death-rate  of  a  place  two 
facts  are  required  to  be  known :  first,  the  actual  or  estimated 
population  (generally  obtained,  as  indicated,  from  the  census), 
and,  second,  the  number  of  persons  who  died  in  the  district 
during  the  year.  The  number  of  deaths  is  divided  by  the  pop- 
ulation, which  gives  the  death-rate  for  each  individual  for  the 
year.  To  find  the  death-rate  per  1000  the  rate  as  found  above 
is  multiplied  by  1000.  Thus,  the  total  number  of  deaths  in  the 
city  of  Philadelphia  during  1893  was  23,655,  and  the  estimated 
population  1,115.562.  The  death-rate  for  the  year  was  21.20 
per  1000,  obtained  as  follows: — 

23,655  X  1000 

-  =  21.20  per  M. 
1,115,562 

To  calculate  the  annual  death-rate  per  1000  of  a  place 
from  the  returns  for  one  week,  the  weekly  population  is  first 
ascertained  and  then  the  number  of  deaths  for  the  week  divided 
by  the  weekly  population  and  the  quotient  multiplied  by  1000. 
The  following  example  will  render  this  clear : — 

The  exact  number  of  weeks  in  a  year  is  52.17747.  The 
total  population  is  divided  by  this  number,  giving  the  weekly 
population.  This  gives  for  Philadelphia,  assuming  the  above 


DEATH-RATE    AND    BIRTH-RATE.  407 

estimate  to  be  correct,  a  weekly  population  of  21,381.  For  the 
week  ending  June  3,  1893,  the  deaths  in  that  city  numbered 
388.  The  annual  death-rate  per  1000, — that  is  to  say,  the 
number  of  deaths  in  each  1000  of  population,  if  the  same  rate 
be  maintained  throughout  the  year, — is  obtained  as  follows  : — 

388  X  1000 

=  18.15  per  M. 

21,381 

The  daily  death-rate  is  obtained  in  a  similar  manner,  the 
divisor  for  obtaining  the  daily  population  being  365.24226, 
and  the  monthly  population  is  found  by  multiplying  the  daily 
population  by  the  number  of  days  in  the  respective  months. 
But  it  should  be  remembered  that  these  rates  for  such  short 
periods  cannot  by  any  means  accurately  indicate  the  actual 
annual  rate,  and  that  they  are  to  be  used  only  for  comparing 
the  rates  for  similar  periods  at  different  seasons,  etc. ;  otherwise, 
with  such  large  populations  and  such  short  periods  the  proba- 
bilities of  error  are  too  great  for  the  results  to  be  of  any  value. 

The  annual  zymotic  or  infectious  death-rate,  or  that  for 
any  one  disease,  is  obtained  in  the  same  manner  as  the  general 
annual  death-rate,  and  likewise  the  birth-rate.  Or,  to  find  the 
annual  death-rate  per  1000  of  population  for  this  class  of  dis- 
eases, the  following  calculation  may  be  made.  Thus,  out  of  the 
above  388  deaths,  84  were  from  infectious  diseases : — 

84  X  1000 

— — — -- —  =  3.93  per  M.  per  annum. 
21 ,381 

Or,  if  the  percentage  of  deaths  from  infectious  diseases  be 
desired,  the  procedure  would  be  as  follows : — 

-  =21.65  per  cent,  of  the  total  deaths. 

388 

As  an  exception  to  the  rule,  the  rate  of  infant  mortality  or 
infantile  death-rate  is  indicated  by  the  ratio  of  deaths  of  chil- 
dren under  one  year  to  the  number  of  births  recorded  for  the 
year,  and  is  found  by  multiplying  the  number  of  infantile  deaths 
by  1000  and  dividing  by  the  number  of  births;  for  example,  for 


408  TEXT-BOOK   OF   HYGIENE. 

the  year  just  quoted  the  decedents  under  one  year  of  age  num- 
bered 5710;  the  total  number  of  births  for  the  same  year  was 
30,737.  Hence,— 

5710  X  1000 

3Q737          =  185.77  per  1000  births. 

Nineteen  of  the  388  deaths  for  the  week  ending  June  3d 
were  of  colored  persons.  The  death-rate  of  these  to  the  total 
population  is  found  in  a  similar  manner  to  the  above;  but  if  it 
is  desired  to  ascertain  the  death-rate  of  the  colored  population 
alone,  the  weekly  colored  population  must  first  be  obtained,  and 
the  rate  calculated  from  this  by  the  above  formula. 

There  are  a  number  of  factors  that  affect  the  general  death- 
rate,  such  as  the  size  of  the  community,  habits  of  life,  age-  and 
sex-  distribution,  occupation  of  the  bulk  of  the  inhabitants,  etc. 
For  the  country  and  small  towns  the  rate  should  be  from  9  to 
16  per  1000,  gradually  increasing  until  for  the  largest  cities  it 
amounts  to  from  18  to  21  per  1000.  Death-rates  reported  below 
these  figures  would  indicate  that  all  the  deaths  had  not  been 
recorded,  or  that  the  population  had  been  overestimated ;  rates 
above  would  be  evidence  that  there  were  special  causes  at  work 
demanding  sanitary  investigation  and  improvement. 

Among  the  causes  that  make  the  mortality  among  infants 
and  children  high  are  parents  too  young  or  sickly,  hereditary 
taints,  unhealthy  environments,  improper  and  insufficient  food 
and  clothing,  and,  not  rarely,  infant  life-insurance.  It  is  simply 
the  manifestation  of  one  of  the  workings  of  the  law  of  "  the 
survival  of  the  fittest."  In  localities  newly  settled,  where  the 
proportion  of  adults  to  children  is  greater  than  the  normal,  the 
death-rate  is  naturally  lower ;  though  it  is  conceivable  that  the 
occupations  in  which  the  adults  engaged  and  the  vicissitudes 
and  unsettled  conditions,  both  sanitary  and  social,  of  a  new 
settlement  might  cause  or  tend  to  cause  a  very  high  mortality. 
Since  more  males  die  than  females,  the  sex-distribution  will  also 
have  its  influence  on  the  death-rate,  especially  if  there  is  a 
preponderance  of  one  sex  over  the  other  in  any  locality. 


DEATH-RATE    AND   BIRTH-RATE.  409 

Many  conditions  affect  the  death-rate  from  the  different 
diseases,  namely,  age,  race,  sex,  occupation,  environment,  sea- 
sons, temperature,  etc.  The  zymotic  death-rate,  and  especially 
that  part  of  it  due  to  typhoid  fever,  may  be  an  extremely  good 
index  of  the  actual  value  and  benefit  of  sanitary  improvements 
and  the  enforcement  of  hygienic  laws.  Thus,  the  mortality 
from  typhoid  fever  in  England  and  Wales  has  been  reduced 
more  than  50  per  cent,  since  the  introduction  and  enforcement 
of  the  general  sanitary  regulations  in  that  kingdom. 

On  account  of  the  lack  of  registration  of  all  cases  of  dis- 
ease, it  is  practically  impossible  to  determine  the  sick-rate  of  a 
community  or  population;  but  it  is  said  that  the  sickness  of  a 
community  amounts  to  the  disablement  of  one  person  for  two 
years  for  every  death,  and  the  records  of  English  beneficial 
societies  seem  to  show  that  each  member  averages  about  one 
and  one-half  weeks'  sickness  annually. 

The  following  definitions  are  introduced  because  the  terms 
are  frequently  used  in  discussions  of  vital  statistics,  and  especially 
of  life-insurance.  The  comparative  mortality  figure  indicates 
that  the  same  number  of  persons  that  gave  1000  deaths  in  the 
whole  population  would  furnish  the  deaths  indicated  by  the 
figure  in  the  city  or  locality  in  question.  Thus,  if  the  com- 
parative mortality  figure  of  a  place  is  925  and  the  death -rate 
of  the  country  is  20,  there  are  1000  deaths  for  every  50,000 
of  the  whole  population  and  the  death-rate  of  the  given  place 
is  18.5.  For  20  : 1000 :  :  x :  925  and  x  =  18.5. 

The  average  or  mean  age  at  death  is  ascertained  by  adding 
up  the  ages  of  all  the  decedents  and  dividing  the  sum  by  the 
number  of  deaths.  Unless  it  is  derived  from  the  life-tables  of 
an  entire  generation,  it  is  not  a  fair  index  of  longevity  or  of 
sanitary  conditions,  since  it  is  affected  considerably  by  the  age- 
distribution  of  the  population  from -which  it  is  compiled. 

The  expectation  of  life  at  any  age  is  the  average  number 
of  years  which  persons  of  that  age  may  expect  to  live.  For  the 
newborn  it  is  the  same  as  the  mean  duration  of  life,  and,  "as 


410  TEXT-BOOK   OF   HYGIENE. 

applied  to  communities,  it  is  the  mean  life-time  of  a  generation 
of  persons  traced  by  the  life-table  method  from  birth  to  death, 
and  is  the  only  true  test  of  the  health  of  populations."  A  life- 
table  is  computed  from  the  number  and  ages  of  the  living;  and 
of  those  that  die,  these  factors  being  obtained  from  the  average 
population  for  each  age  and  sex,  and  from  the  total  death- 
returns  between  two  or  more  censuses.  It  is,  as  Dr.  Farr 
says,  "  a  barometer  which  indicates  the  exact  measure  of  the 
duration  of  life  under  given  circumstances,  and  is  indispensable 
in  gauging  the  influence  of  sanitary  or  insanitary  conditions." 

It  is  only  when  the  population  does  not  vary  as  to  age-  or 
sex-  distribution  that  the  mean  duration  of  life  is  identical  with 
the  average  age  at  death.  Otherwise,  for  any  person  at  any  age 
it  is  the  same  as  the  expectation  of  life.  The  probable  duration 
of  life  is  equivalent  to  the  age  at  which  any  number  of  newborn 
children  will  be  reduced  one-half,  the  same  conditions  persist- 
ing. With  a  million  children  as  a  basis,  it  is  less  than  forty- 
five  years  for  males  and  about  forty-seven  years  for  females. 

It  will  be  evident,  on  a  little  thought,  that  there  must  be 
many  sources  of  error  in  calculations  based  upon  such  uncertain 
data  as  are  derived  from  the  registration  of  births  and  deaths  as 
conducted  in  most  cities  in  this  country.  Besides,  the  subject 
of  vital  statistics  is  essentially  abstruse,  and  requires  no  little 
readiness  in  mathematics  to  appreciate  its  profounder  bearings. 
Hence,  in  the  foregoing  chapter,  no  attempt  has  been  made  to 
penetrate  beyond  the  immediate  practical  aspects  of  the  ques- 
tions involved. 

[To  those  desiring  fuller  information  upon  this  subject  the 
following  works  are  recommended : — 

Curtis,  "  Vital  Statistics,"  in  Buck's  Hygiene  and  Public  Health. — 
Billings,  "  Registration  of  Vital  Statistics,"  American  Journal  of  Medical 
Sciences,  vol.  Ixxxv. — Oldendorff,  "  Morbilitsets  und  Mortal! ta?ts-Stutis- 
tik,"  ne  Realencyclopa?die  d.  ges.  Heilk.,  Bd.  ix. — Billings,  "  Papers  on 
Vital  Statistics,"  Sanitary  Engineer,  vols.  viii  and  ix. — Ibid.,  Cartwright 
Lectures  on  Vital  and  Medical  Statistics,  1890. — Wilson,  Hand-book  of 
Hygiene  and  Sanitary  Science.] 


QUESTIONS   TO    CHAPTER  XXI. 

VITAL  STATISTICS. 

What  is  comprised  in  the  registration  of  vital  statistics  ?  How  are 
they  to  be  made  of  use  ?  Of  what  value  are  the  recorded  statistics  to 
the  sanitarian?  How  else  may  disease  be  studied?  Why  may  not  the 
same  methods  of  determining  the  general  health  be  applied  to  large  com- 
munities as  to  small  ones? 

What  is  the  census  ?  What  returns  of  interest  to  the  sanitarian  does 
it  make?  Which  of  these  are  the  most  important?  Why?  What  is 
the  advantage  of  furnishing  returns  for  "  sanitary  districts,"  and  what 
is  meant  by  the  latter? 

What  returns  are  to  be  obtained  from  the  registration  bureau  ?  Who 
furnishes  these  returns  ?  Who  should  have  charge  of  the  registration  ? 
Why?  Why  should  physicians  make  the  returns?  Why  should  the 
State  take  care  in  the  licensing  of  physicians  to  practice  ?  What  is  the 
most  important  object  of  the  registration  of  vital  statistics? 

What  are  the  fundamental  principles  underlying  all  statistical  in- 
quiry ?  What  units  or  cases  should  be  omitted  ?  What  renders  the 
classification  of  groups  difficult?  What  is  the  usual  standard  of  com- 
parison ?  When  is  the  relation  of  component  groups  to  the  total  con- 
stant? How  may  the  probable  limit  of  variation  be  determined?  What 
tends  to  make  the  arithmetical  mean  approach  the  invariable  ?  How  may 
the  relative  value  of  different  series  of  the  same  kind  of  cases  be  deter- 
mined? What  is  the  difference  between  averages  and-  extreme  values  ? 
Of  what  value  is  the  graphic  method  of  representing  statistical  results? 

What  are  the  units  of  vital  statistics  ?  How  may  they  be  divided 
into  groups  ?  What  is  the  natural  increment  of  a  population  ?  How 
does  this  differ  from  the  actual  increment?  If  the  factors  were  constant, 
how  would  a  population  increase?  Why  ?  Why  cannot  the  population 
be  determined  exactly  for  intercensal  periods  ?  What  is  the  usual 
and  most  accurate  way  of  determining  it  ?  How  else  may  it  be  esti- 
mated ?  What  is  the  fault  of  counts  made  by  local  authorities  or  police 
censuses  ?  At  what  time  of  the  year  is  the  count  always  made  ?  For 
what  time  are  annual  death-rates,  etc.,  calculated? 

Why  is  the  collection  of  data  for  birth-records  difficult  ?  Who 
should  make  the  return?  What  items  are  usually  included  in  the 
returns?  Which  are  the  only  ones  of  value  to  the  sanitarian  and 
medical  statistician  ?  Why  is  the  record  of  marriages  of  no  sanitary 
interest  ?  llow  might  it  be  made  so  ?  Is  this  practicable  ? 

(411) 


412  QUESTIONS   TO   CHAPTER   XXI. 

What  classes  of  diseases  should  be  reported  and  recorded  ?  Why  ? 
What  epidemic  diseases  might  escape  notice  by  the  statistician  if  only 
reported  in  death-returns  ?  When  should  the  returns  of  infectious  dis- 
eases be  made?  Should  there  be  any  recompense  for  the  returns  to  the 
physicians  ? 

What  data  should  be  given  by  a  death-certificate  ?  Which  items 
should  be  accurately  specified  ?  What  care  should  be  taken  in  reporting 
the  cause  of  death  ?  When  should  the  burial-permit  be  issued  ? 

What  factors  are  required  in  order  to  calculate  the  death-rate  of  a 
locality  ?  How  is  the  death-rate  for  the  year  obtained  ?  How  may  the 
annual  death-rate  of  a  place  be  calculated  from  the  death-returns  for  one 
week  ?  What  is  the  weekly  and  the  daily  population  ?  How  is  the 
monthly  population  found  ?  What  is  the  objection  to  rates  determined 
from  returns  for  such  short  periods?  Of  what  value  are  they  ? 

What  is  meant  by  the  zymotic  or  infectious  death-rate  ?  How  may 
it  be  determined?  How  is  the  percentage  of  deaths  due  to  infectious 
disease  determined  ?  How  is  the  rate  of  infant  mortality  determined  ? 

What  factors  affect  the  general  death-rate  ?  What  is  a  fair  death- 
rate  for  small  communities  ?  For  large  cities  ?  What  do  higher  rates 
than  this  usually  indicate  ?  What  do  lower  ones  ?  What  causes  make 
the  mortality  so  high  among  infants  and  young  children  ?  What  may 
make  the  death-rate  of  a  community  lower  than  the  normal?  What 
higher?  How  may  sex-distribution  affect  the  death-rate?  What  con- 
ditions or  factors  affect  the  mortality  from  the  different  diseases  ?  How 
may  the  zymotic  death-rate  be  an  index  of  the  value  of  sanitary 
measures  ? 

Why  is  it  so  difficult  to  determine  the  sick-rate  of  a  community  ? 
How  may  the  total  amount  of  sickness  be  approximately  estimated  ? 

What  is  meant  by  the  comparative  mortality  figure  ?  What  by  the 
average  age  at  death  ?  Is  this  necessarily  a  fair  index  of  longevitj7  ? 
What  affects  it  ?  What  is  meant  by  the  expectation  of  life  ?  Of  what 
value  is  it  when  applied  to  communities  ?  What  is  a  life-table,  and  how 
is  it  computed  ?  Of  what  value  is  it  to  sanitarians  ?  When  is  the  mean 
duration  of  life  identical  with  the  average  age  at  death  ?  What  is  meant 
by  the  probable  duration  of  life  ?  Why  are  calculations  of  vital  statistics 
liable  to  be  unreliable  or  inaccurate  ? 


CHAPTER  XXII. 

THE  EXAMINATION  OF  Am,  WATER,  AND  FOOD. 

(By  SKNECA  EGBERT,  A.M.,  M.D.,  Professor  of  Hygiene,  Medico-Chirurgical 
College,  Philadelphia.) 

OCCASIONS  often  arise  wherein  physicians  or  others  desire 
information  concerning  the  atmosphere  of  apartments  or  con- 
fined spaces,  the  quality  of  a  drinking-water,  or  regarding  cer- 
tain articles  of  food.  They  have  neither  time,  apparatus,  nor, 
possibly,  the  peculiar  skill  necessary  to  obtain  the  accurate 
results  of  the  expert  chemist  or  bacteriologist;  nor  do  they 
require  that  the  information  which  they  seek  should  be  so 
extremely  exact.  What  they  do  wish  is  to  know  whether  the 
object  in  question  is  sufficiently  pure  or  safe  to  use  from  a 
sanitary  point  of  view,  and,  if  not,  wherein  it  is  deficient  or 
harmful. 

In  the  preparation  of  this  chapter,  therefore,  such  methods 
of  procedure  will  be  detailed  as  will  serve  to  determine,  with 
reasonable  accuracy  and  with  moderate  requirements  of  time, 
expense,  or  technical  skill,  the  hygienic  condition  of  the  sub- 
stances examined.  The  apparatus  and  reagents  will  also  be 
found,  for  the  most  part,  to  be  cheap  and  easily  obtainable,  and 
they  may  often  be  improvised  or  prepared  from  material  already 
at  hand.  Moreover,  a  little  thought  will  show  how  a  number 
of  these  methods  may  be  developed  along  the  line  of  greater 
accuracy,  should  this  be  desired,  and  the  principles  involved 
will  indicate  how  similar  examinations  may  be  made  of  other 
phases  of  the  respective  subjects  not  herein  discussed. 

THE    EXAMINATION    OF  AIR. 

As  has  been  indicated  in  Chapter  I,  the  substances  in  the 
atmosphere  whose  proportions  or  characteristics  it  may  be  im- 
portant to  determine  are:  the  aqueous  vapor;  ozone;  suspended 

(413) 


414  TEXT-BOOK   OF   HYGIENE. 

particles,  both  organic  and  inorganic;  living  micro-organisms; 
volatile  organic  matters,  and  the  various  gases  given  off  as 
products  of  respiration,  combustion,  etc.,  or  in  the  course  of 
certain  manufacturing  processes. 

The  proportion  of  aqueous  vapor  is  to  be  determined  by 
some  form  of  hygrometer,  such  as  Lambrecht's  poly  meter,  or 
from  the  readings  of  wet-  and  dry-  bulb  thermometers,  which 
readings,  when  applied  to  Glaisher's  tables,  furnish  a  means  of 
determining  the  relative  and  the  absolute  humidity,  the  dew- 
point,  the  weight  of  water  to  a  given  volume  of  air,  etc. 

The  presence  of  ozone  in  the  atmosphere  may  be  demon- 
strated by  exposing  to  the  air  strips  of  white  blotting-  or  filter- 
paper  which  have  been  saturated  with  a  solution  of  potassium 
iodide  and  starch  and  dried.  The  ozone,  decomposing  the 
potash  salt,  liberates  the  iodine  and  colors  the  starch  blue. 
During  the  test  the  paper  should  not  be  exposed  to  dust,  rain, 
wind,  or  the  direct  rays  of  the  sun.  Another  test  (Houzeau's), 
perhaps  even  more  delicate,  is  to  dampen  a  strip  of  faintly-red 
litmus-paper  with  a  solution  of  the  iodide  and  dry.  The  action 
of  ozone  upon  this  is  to  liberate  the  alkaline  potash  and  change 
the  litmus  to  blue.  As  ammonia  is  the  only  other  gas  likely  to 
produce  the  same  coloration,  if  another  strip  of  the  litmus- 
paper,  not  moistened  with  the  salt,  be  exposed  at  the  same  time, 
whatever  difference  in  shade  there  may  be  in  the  papers  is  due 
to  the  ozone.  An  idea  of  the  quantity  of  ozone  present  may 
also  be  gained  by  comparing  the  shade  of  blue  given  by  either 
test  with  that  produced  in  similar  strips  of  the  starch-  or  litmus- 
paper,  respectively,  which  have  been  exposed  to  certain  definite 
amounts  of  ozone,  a  series  of  such  papers  forming  a  standard 
of  comparison. 

It  may  be  suggested,  for  still  another  test,  that  a  definite 
quantity  of  the  air  to  be  examined  be  drawn  through  a  faintly- 
acid  solution  of  the  potassium  iodide,  phenol  phthaleine  being 
used  as  an  indicator.  As  soon  as  sufficient  alkali  is  liberated 
to  neutralize  the  acidity,  the  pink  color  of  the  phenol  phthal- 


THE   EXAMINATION    OF    AIR.  415 

eine  will  be  developed  and  will  deepen  as  the  proportion  of 
free  alkali  increases.  Here,  also,  a  control-test  to  eliminate  the 
influence  of  ammonia  should  be  made  by  drawing  a  similar 
quantity  of  air  through  the  same  amount  of  the  solution  minus 
the  potassium  iodide.  As  before,  the  difference  in  color-shading 
will  be  proportional  to  the  amount  of  ozone  in  the  air. 

Numerous  methods  have  been  suggested  for  the  collection 
of  the  solid  impurities  of  the  atmosphere,  varying  according  to 
the  kind  or  extent  of  examination  to  which  they  are  to  be  sub- 
jected. If  they  are  simply  to  be  studied  microscopically,  glass 
slides  coated  with  glycerin  and  exposed  to  the  air,  as  described 
on  page  37,  will  be  sufficiently  covered  after  several  hours,  or 
they  may  be  collected  more  rapidly  by  aspirating  large  quanti- 
ties of  the  air  against  such  slides  or  through  tubes  coated 
interiorly  with  glycerin,  as  by  means  of  Pouchet's  aeroscope  or 
by  the  apparatus  devised  by  Dr.  S.  G.  Dixon.  This  latter  is 
especially  advantageous  where  it  is  desired  to  collect  samples  of 
dust  in  the  air  of  a  number  of  localities  within  a  short  time,  and 
consists  essentially  of  a  double  cylinder  of  metal,  within  which 
is  a  rack  carrying  a  number  of  glycerin-  or  gelatin-  smeared 
cover-glasses.  By  an  ingenious  arrangement  the  air  can  be 
aspirated  by  means  of  a  hand-bulb  over  each  of  these  glasses 
in  turn,  the  dust-particles  being  deposited  on  the  sticky  surface, 
and  thus  the  samples  may  be  taken  from  as  many  localities  as 
there  are  cover-glasses.  Moreover,  the  specimens  may  be 
mounted  and  examined  as  they  are,  may  be  stained,  or,  if  the 
glasses  be  coated  with  gelatin  and  the  whole  apparatus  be  ster- 
ilized before  the  collection,  colonies  of  the  bacteria,  etc.,  in  the 
dust  may  be  allowed  to  develop  on  the  glasses  and  be  studied 
in,  loco  under  the  microscope. 

Another  satisfactory  method  of  collecting  suspended  par- 
ticles is  to  draw  a  considerable  volume  of  air  very  slowly 
through  a  small  quantity  of  distilled  water  contained  in  one 
or  two  wash-bottles.  The  solid  particles  may  then  be  allowed 
to  settle,  and  subsequently  be  removed  for  microscopical  ex- 


416  TEXT-BOOK   OF   HYGIENE. 

amination  by  means  of  a  pipette,  or  the  whole  may  be  filtered 
and  the  weight  of  the  dust  in  the  aspirated  air  thus  obtained. 
It  might  also  be  well,  in  the  latter  case,  to  evaporate  the  filtrate 
to  dryness  and  to  determine  what  proportion  of  the  residue  is 
organic  matter,  and  what  is  its  nature  and  effects  when  admin- 
istered to  animals.  Lastly,  the  air  may  be  slowly  drawn  through 
a  small  tube  packed  with  pure  sugar,  the  sugar  afterward  being 
dissolved  in  distilled  water,  whence  the  solid  particles  taken 
from  the  air  may  be  removed  by  means  of  a  pipette  or  by 
filtration. 

The  physical  nature  of  the  particles  of  dust  thus  collected 
is  to  be  determined  by  means  of  the  microscope,  it  being  pre- 
sumed that  the  examiner  is  sufficiently  familiar  with  the  instru- 
ment to  recognize  at  sight  the  more  common  materials  that  are 
apt  to  pervade  the  air  of  occupied  apartments,  such  as  bits  of 
cotton,  wool,  hair,  epithelium,  etc.  Charring  on  ignition  will 
indicate  that  the  residue  is,  at  least,  partly  organic,  and  the 
odor  of  burnt  feathers  that  it  is  nitrogenous  and  probably  of 
animal  origin.  Suitable  chemical  tests  will  also  determine  the 
presence  or  absence  of  suspected  substances.  Thus,  an  ex- 
amination of  the  dust  by  Marsh's  or  Reinsch's  test  may  reveal 
the  presence  of  arsenic,  and  lead  to  an  investigation  as  to  its 
source. 

However,  since  Cornet  and  others  have  demonstrated  that 
the  micro-organisms  in  the  air  are,  in  general,  closely  adherent 
to  the  dust-particles,  a  bacteriological  examination  of  the  latter 
will,  except  in  special  cases,  be  of  more  importance  than  a 
physical  or  chemical  one. 

To  make  a  qualitative  bacteriological  examination  it  is 
only  necessary  to  coat  the  glass  plates  or  tubes,  already  de- 
scribed, with  nutrient  gelatin  instead  of  glycerin,  and  to  ster- 
ilize them  before  use.  They  are  then  exposed  to  the  air  as 
before,  covered,  and  set  aside  in  a  place  of  proper  temperature 
to  allow  the  colonies  to  develop  from  the  various  micro-organ- 
isms which  have  adhered  to  the  sticky  surfaces;  or  Dr.  Dixon's 


THE   EXAMINATION   OF   AIR.  417 

apparatus,  with  gelatin-coated  glasses,  may  be  used  in  the 
manner  described. 

A  quantitative  bacteriological  examination  is  almost  as 
readily  made  by  drawing  a  given  quantity  of  air  through  a  sugar- 
filter,  as  stated.  The  tube  should  not  be  too  large  in  diameter 
nor  in  length,  should  be  tilled  with  pure  granulated  sugar  and 
the  ends  temporarily  plugged  with  cotton,  and  should,  of  course, 
be  sterilized,  before  making  the  test.  After  the  air  has  been 
drawn  through  it  the  sugar  is  carefully  emptied  into  tubes  or 
flasks  of  nutrient  gelatin,  which  have  been  heated  just  enough 
to  melt  the  gelatin,  but  not  sufficiently  high  to  kill  the  bacteria, 
etc.,  which  have  been  caught  in  the  sugar.  The  latter  rapidly 
dissolves  and  leaves  the  micro-organisms  free  to  develop  in  the 
gelatin,  which  may  be  poured  out  before  cooling  upon  steril- 
ized glass  plates  or  into  shallow  (Petri)  dishes.  So-called  col- 
onies rapidly  develop  from  the  individual  bacteria,  and  the  total 
number  of  these  colonies  may  be  assumed  to  represent  the 
number  of  micro-organisms  in  the  quantity  of  air  aspirated 
through  the  filter.  Moreover,  from  these  colonies  pure  cultures 
may  be  made  and  the  nature,  etc.,  of  their  respective  microbes 
determined.  To  determine  the  quantity  of  organic  matter  in  the 
air  the  most  feasible  method  is  to  slowly  draw  a  certain  volume 
of  air  through  a  given  quantity  of  twice-distilled  ammonia-free 
water,  which  retains  not  only  all  the  volatile  and  suspended 
organic  matters,  but  also  the  gases  originating  therefrom.  The 
water  is  then  to  be  tested  by  the  Wanklyn  process  for  "  free  " 
and  "  albuminoid  "  ammonia,  and,  if  desired,  by  the  Tidy-For- 
chanirner  process  for  oxidizable  organic  matter,  though  it  should 
be  noted  that  in  the  latter  process  other  gases  present  in  the 
air,  such  as  sulphuretted  hydrogen,  may  help  to  decolorize  the 
permanganate  solution,  and  must  therefore  be  excluded  or 
estimated  separately. 

However,  as  these  processes  are,  perhaps,  too  complex  for 
the  purpose  of  this  chapter,  and  as  it  has  been  shown  by  de 
Chaumont  and  others  that  the  organic  matter  with  which  we 


n 


418  TEXT-BOOK    OF    HYGIENE. 

are  usually  most  concerned — namely,  that  given  off  from  human 
bodies  as  a  product  of  respiration  and  like  processes — is  pro- 
duced in  quantities  proportional  to  the  amount  of  carbon  dioxide 
eliminated  in  the  same  processes,  it  generally  suffices  for  our 
purpose  to  determine  the  proportion  of  this  gas  in  the  atmos- 
phere, especially  as  this  determination  is  much  more  readily 
made  than  the  foregoing  one. 

The  methods  devised  by  Wolpert  and  Angus  Smith  for 
rapidly  estimating  the  percentage  of  carbon  dioxide  have 
already  been  given  on  pages  33-36,  but  the  following  modifica- 
tions of  these  methods  will,  it  is  believed,  materially  simplify 
them. 

Professor  Boom  has  suggested  that,  instead  of  the  special 
and  somewhat  expensive  apparatus  of  Professor  Wolpert,  a 
mark  be  made  on  any  test-tube, — say,  one  inch  from  the  bottom. 
Fix  the  bulb  of  any  atomizer  to  a  small  glass  tube — a  capillary 
one,  if  possible — sufficiently  long  to  reach  to  the  bottom  of  the 
test-tube,  and  in  such  a  manner  that  a  definite  volume  of  air  is 
driven  from  the  atomizer-bulb  through  the  tube  at  each  com- 
pression of  the  former.  In  using,  fill  the  test-tube  exactly  to 
the  mark  with  a  clear,  saturated  solution  of  lime-water,  and 
find  how  many  compressions  are  needed  in  the  out-door  air — 
forcing  the  air  through  the  lime-water  each  time  and  taking 
care  not  to  draw  any  fluid  up  into  the  bulb — to  make  the  fluid 
just  turbid  enough  to  obscure  a  pencil-mark  or  print  on  white 
paper  placed  beneath  the  test-tube  and  viewed  from  above. 
Clean  the  test-tube  thoroughly,  and  repeat  the  process  in  the 
apartment  of  which  the  air  is  to  be  examined.  Assuming 
that  the  out-door  air  contains  the  normal  proportion  of  carbon 
dioxide, — viz.,  0.04  per  cent., — the  percentage  in  the  air  of  the 
room  is  determined  as  follows : — 

The  number  of  compressions  of  the  bulb  in  the  out-door 
air  :  the  number  of  compressions  in  the  room  :  :  x  :  0.04  per 
cent.,  x  representing  the  percentage  of  carbon  dioxide  in  the 
air  of  the  room. 


THE   EXAMINATION    OF   AIR.  419 

As  a  modification  of  the  Angus  Smith  method,  the  author 
would  suggest  the  following  as  being,  perhaps,  more  accurate, 
and  as  certainly  not  requiring  so  much  apparatus,  etc. : — 

To  a  wide-mouthed  bottle,  holding  about  a  quart  or  litre, 
fit .  a  doubly-perforated  rubber  stopper,  one  perforation  being 
just  large  enough  to  receive  the  tip  of  a  1  c.  c.  pipette,  the  other 
carrying  a  small  test-tube,  its  mouth  opening  into  the  jar  and 
close  to  the  inner  surface  of  the  stopper.  Fill  the  bottle  and 
test-tube  with  the  air  of  the  room  by  filling  them  with  water 
and  emptying ;  fit  in  the  stopper,  and  introduce,  by  means  of 
a  1  c.  c.  pipette,  a  cubic  centimetre  at  a  time  of  a  standardized 
alkaline  solution,  slightly  colored  with  a  few  drops  of  a  neutral 
alcoholic  solution  of  phenol  phthaleine.  Close  the  pipette  per- 
foration in  the  stopper  with  a  bit  of  glass  rod  and  shake  the 
bottle  well  each  time  after  adding  the  alkaline  solution.  Con- 
tinue in  this  way  until  the  color  is  no  longer  discharged  by  the 
acid  carbon  dioxide  of  the  air.  By  having  the  test-tube  fitted 
in  the  stopper  as  above  and  inverting  the  bottle,  the  same 
thickness  of  fluid  is  observed  each  time,  and  there  is  more 
accuracy  than  if  the  bottle  is  used  without  the  test-tube.  In 
either  case  the  fluid  should  be  examined  by  looking  through  it 
against  a  white  light  or  surface. 

Now,  since  the  quantity  of  the  alkaline  fluid  used  indi- 
cates a  correspondingly  definite  amount  of  carbon  dioxide, — 

the  number  of  c.  c.  of  solution  used  X  the  volume  of  COt  each  c.  c.  repretentt  X  100 
the  capacity  of  the  bottle  and  test-tube  in  c.  c.  —  the  number  of  c.  c.  of  solution  used 

=  the  percentage  of  carb.on  dioxide  in  the  air  examined. 

A  suitable  alkaline  solution  may  be  prepared  by  dissolving 
exactly  4.766  grammes  (73.549  grains)  of  pure  anhydrous 
sodium  carbonate  in  1  litre  (35.238  fluidounces)  of  distilled 
water.  Each  cubic  centimetre  of  this  solution  is  equivalent  to 
a  like  volume  of  carbon  dioxide.  To  10  cubic  centimetres  of 
this  solution  add  a  few  drops  of  a  neutral  alcoholic  solution  of 
phenol  phthaleine  and  dilute  with  distilled  water  to  100  c.  c. 
Each  cubic  centimetre  of  the  dilute  solution  will  now  be  neu- 


420  TEXT-BOOK   OF    HYGIENE. 

tralized  by  0.1  c.  c.  of  carbon  dioxide,  and,  if  used  as  suggested, 
should  give  close  results.  The  phenol  phthaleine  is  used  as  an 
indicator,  as  it  loses  its  color  as  soon  as  the  alkalinity  of  the 
soda  solution  is  destroyed  by  the  carbonic  acid.  Example  :  If 
1 1  c.  c.  of  the  foregoing  dilute  solution  be  used,  and  the  capacity 
of  the  bottle  and  test-tube  is  1153  c.  c.,  then 

11X0.1X  100  _  110 

1153—11       ~1142~          53'~~ 

the  percentage  of  carbon  dioxide  in  the  air  of  the  apartment. 
The  first  (stock)  solution  must  be  kept  in  well-filled  and 
tightly-stoppered  bottles,  and  the  dilute  solution  made  up  as 
needed. 

Pettenkofer's  method  for  determining  the  percentage  of 
carbon  dioxide  in  the  air,  which  is  usually  considered  the  best,  is 
as  follows:  Into  a  large,  clean  bottle  or  jar,  filled  with  the  air 
of  the  room  as  on  page  419,  introduce  50  c.  c.  of  a  clear,  satu- 
rated solution  of  lime  (calcium  hydrate),  stopper  the  bottle,  and 
shake  it  well,  so  that  the  air  may  be  well  washed  by  the  lime- 
water.  This  shaking  should  be  repeated  at  intervals  for  several 
hours,  from  eight  to  ten  hours  being  required  for  the  lime-water 
to  absorb  all  the  carbon  dioxide  in  the  air  in  the  jar.  (How- 
ever, if  baryta — barium  hydrate — water  be  used  instead  of  the 
lime-water,  the  absorption  will  be  completed  in  an  hour.) 

The  strength  of  the  lime-  (or  baryta-)  water  being  un- 
known and  variable,  it  is  determined  by  means  of  an  oxalic-acid 
solution  of  such  strength  that  1  c.  c.  corresponds  in  acidity  to 
0.5  c.  c.  of  carbon  dioxide.  Such  a  solution  is  made  by  dis- 
solving exactly  2.84  grammes  (43.827  grains)  of  pure  crystal- 
lized oxalic  acid,  in  1  litre  of  freshly-distilled  water.  This 
acid  solution  is  run  into  25  c.  c.  of  the  lime-water  in  a  beaker 
from  a  graduated  burette,  or  pipette,  until  the  alkalinity  of  the 
lime  is  just  neutralized,  the  neutral  point  being  indicated  either 
by  means  of  a  few  drops  of  a  neutral  phenol-phthaleine  solution 
in  the  beaker  or  by  turmeric  paper,  the  latter  being  colored 
brown,  and  the  phenol  phthaleine  retaining  its  color  as  long  as 


THE   EXAMINATION    OF    AIR.  421 

the  solution  is  alkaline.  When  the  lime  is  exactly  neutralized 
the  amount  of  acid  solution  used  from  the  burette  is  noted. 
Then  25  c.  c.  of  the  lime-water  from  the  testing-bottle  is  meas- 
ured into  a  beaker,  and  its  acidity  determined  in  the  same 
manner  by  means  of  the  oxalic-acid  solution.  Now,  since  part 
of  the  lime  in  the  solution  in  the  testing-bottle  has  already 
been  neutralized  by  the  carbonic  acid  of  the  air  therein,  it  will 
require  less  of  the  acid  solution  to  neutralize  the  lime-water 
from  the  bottle  than  it  did  to  neutralize  the  same  quantity  from 
the  stock  solution,  and  the  difference  will  indicate  the  exact 
amount  of  carbon  dioxide  in  the  air  in  the  testing-bottle.  For, 
though  each  cubic  centimetre  of  acid  solution  is  equivalent  to 
only  one-half  cubic  centimetre  of  carbon  dioxide,  the  loss  of 
alkalinity  of  only  half  the  lime-water  in  the  bottle  has  been  de- 
termined, and  the  total  loss  would  be  expressed  by  twice  the 
difference  found.  The  number  of  cubic  centimetres  of  carbon 
dioxide  in  the  air  in  the  bottle  having  been  thus  determined, 
and  the  capacity  of  the  bottle  found  by  measuring  the  quantity 
of  water  it  will  hold,  the  percentage  of  carbon  dioxide  in  the 
air  is  readily  determined.  For  example  :  25  c.  c.  of  stock  lime- 
water  requires  30  c.  c.  acid  solution,  and  25  c.  c.  of  lime-water 
from  testing-bottle  requires  27  c.  c.  acid  solution  ;  therefore, 
30  —  27  =  3  c.  c., — the  amount  of  carbonic  acid  in  the  bottle, 
which  contains,  say,  2550  c.  c.  Then— 

3  X  100         300  _=012_ 


2550  —  50       2500 

the  percentage  of  carbon  dioxide  in  the  room  at  the  current 
temperature  and  pressure.  It  should  be  noted  that  the  accuracy 
of  all  these  tests  is  somewhat  vitiated  by  other  acid  gases,  if 
present  in  the  air,  and  due  allowance  should  be  made  wherever 
they  are  suspected. 

As  has  been  intimated,  baryta-water  may  be  used  in  place 
of  the  lime-water,  being  more  rapid  in  action,  but  considerably 
more  expensive,  than  the  latter.  The  solution  should  be  made 
of  the  strength  of  about  7  grammes  of  crystallized  barium 


422  TEXT-BOOK   OF   HYGIENE. 

hydrate  to  the  litre  of  distilled  water ;  it  must  not  be  forgotten, 
also,  that  it  is  poisonous  when  taken  internally.  A  good  indi- 
cator, in  addition  to  the  phenol  phthaleine  and  turmeric,  is 
methyl-orange,  which  is  yellow  in  alkaline  and  of  a  reddish  tint 
in  acid  solutions. 

The  quantity  of  ammonia  in  the  atmosphere  may  be  de- 
termined by  drawing  a  certain  volume  of  air  through  twice- 
distilled  water  and  then  "  Nesslerizing "  the  latter,  as  in  the 
Wanklyn  process  of  water  analysis.  So,  also,  the  presence  and 
percentage  of  other  gases,  such  as  nitric,  hydrochloric,  sulph- 
urous, and  sulphuric  acid,  sulphuretted  hydrogen,  ammonium 
sulphide,  etc.,  are  obtained  by  drawing  the  air  through  distilled 
water  and  subsequently  making  the  proper  chemical  tests.  For 
instance,  the  sulphur  gas  will  darken  a  solution  of  lead  acetate 
and  ammonium  sulphide  will  change  the  blue  color  of  nitro- 
prusside  of  sodium  to  violet;  consequently,  the  air  may  be 
drawn  through  standard  solutions  of  these  reagents  and  the 
resulting  coloration  compared  with  that  produced  by  known 
quantities  of  the  respective  gases. 

As  indicated  on  page  36,  the  presence  of  carbon  monoxide 
is  shown  by  the  darkening  of  a  solution  of  palladium  chloride 
or  sodio-chloride,  but  a  more  delicate  test  is  that  of  Vogel  by 
means  of  the  spectroscope,  which  will  show  the  presence  of  as 
little  as  0.03  per  cent,  of  the  gas.  In  this  test  a  drop  of  fresh 
blood  is  mixed  with  a  little  pure  water  and  the  mixture  well 
shaken  with  a  sample  of  the  air  in  a  jar.  Then  a  few  drops  of 
ammonium  sulphide  a"re  added  and  the  fluid  examined  spectro- 
scopically.  If  carbon  monoxide  is  present  the  spectrum  of  oxy- 
hsemoglobin  will  be  seen,  it  not  having  been  reduced  by  the 
ammonium  sulphide ;  but  if  the  carbon  monoxide  is  not 
present,  we  shall  have  the  spectrum  of  reduced  haemoglobin. 

As  even  very  small  quantities  of  carbon  monoxide  in  the 
air  are  harmful,  it  will  not  often  be  necessary  to  make  a  quan- 
titative test  for  it;  but  should  this  be  desired,  it  can  be  done  by 
passing  a  given  volume  of  air  several  times  through  a  solution 


THE   EXAMINATION    OF   WATER.  423 

of  subchloride  of  copper,  which  absorbs  the  carbon  gas,  and 
then  determining  the  loss  of  volume  the  air  has  suffered  by 
means  of  the  eudiometer. 

THE   EXAMINATION    OF   WATER. 

A  number  of  tests  for  impurities  in  water  have  already 
been  given  on  pages  74  to  79,  but,  as  these  are  mainly  qualita- 
tive in  character,  the  author  of  the  present  chapter  takes  the 
liberty  of  subjoining  the  following  ones,  in  "addition,  for  the 
benefit  of  those  who  may  desire  a  more  or  less  accurate  quanti- 
tative knowledge  of  the  various  substances  in  a  water  that  may 
affect  its  purity  from  a  hygienic  stand-point. 

Care  should  be  observed,  in  collecting  samples,  that  they 
may  fairly  represent  the  water  to  be  examined,  and  not  contain 
an  excess  of  impurities.  Sufficient  of  the  water  should  be 
taken  for  all  the  tests, — say,  two  or  three  quarts,  at  least, — and 
the  receptacles  must  be  chemically  clean,  preferably  of  glass, 
and  not  of  tin  or  metal,  and  should  be  thoroughly  rinsed  several 
times  with  the  water  before  being  finally  filled.  The  stoppers 
must  also  be  clean,  and  should  also  be  tight  enough  to  prevent 
the  escape  of  gases,  as  these  latter  often  naturally  hold  in  solu- 
tion substances  which  would  otherwise  go  to  make  the  water 
turbid,  and  the  loss  of  which  by  precipitation  might  possibly 
change  its  character.  Notes  should  be  made  of  the  time,  place, 
surroundings,  etc.,  when  each  sample  is  collected,  and  as  much 
information  as  possible  obtained  of  the  conditions  which  may 
affect  the  purity  of  the  water.  If  it  is*  taken  from  lakes  or 
reservoirs,  the  sample  should  be  from  some  little  distance 
below  the  surface ;  if  from  hydrants  or  pumps,  the  water  should 
be  allowed  to  flow  awhile,  so  that  the  sample  may  be  from  the 
main  source  of  supply,  and  not  from  that  which  has  been 
standing  in  the  pipe  or  from  storage-tanks.  All  the  tests 
except  those  for  the  turbidity,  sediment,  nitrogen  as  ammonia 
or  as  organic  matter,  and  for  the  oxygen-consuming  power, 
should  be  made  with  water  which  has  been  cleared  by  sub- 


424  TEXT-BOOK    OF    HYGIENE. 

sidence  or  filtration ;  those  mentioned  should  be  made  with  the 
sample  as  taken  from  the  source  of  supply. 

As  indicated  in  Chapter  II,  the  tests  for  color,  turbidity, 
etc.,  are  made  by  comparing  the  sample  with  an  equal  volume 
of  distilled  water,  using  tall,  glass  jars  of  the  same  calibre,  and 
looking  down  through  equal  depths  upon  a  white  surface.  Or 
the  turbidity  may  be  indicated  by  noting  the  depth  which  is 
required  to  obscure  print  from  type  of  a  certain  size  or  font. 

The  smell  may  be  detected  by  heating  the  water  to  from 
40°  to  60°  C.  (104°  to  140°  F.)  in  a  glass-stoppered  bottle. 
Sometimes  the  higher  temperature  is  needed  to  liberate  odorous 
gases  that  would  otherwise  be  undetected,  and,  again,  there  is 
often  no  smell  at  all  from  a  very  bad  water  or  from  one  from  an 
obnoxious  source.  The  test,  therefore,  may  or  may  not  indicate 
sewage  or  faecal  contamination. 

The  impurities  that  give  any  perceptible  taste  to  water, 
except  when  in  large  amounts,  are  very  few  in  number,  and 
many  waters  dangerously  polluted  have  a  good  and  pleasing 
taste.  Of  the  metals,  iron  is  the  only  one  which  is  perceptible 
to  the  taste  in  small  quantities ;  but  one-fourth  of  a  grain  of 
this  base  to  the  gallon  may  thus  indicate  its  presence.  Caution 
should,  of  course,  be  observed  in  tasting  waters  suspected  of 
containing  infectious  or  poisonous  matters. 

The  proportion  of  air  or  gas  a  water  contains  is  indicated, 
in  a  measure,  by  its  lustre  and  by  the  presence  of  bubbles  on  the 
sides  and  bottom  of  the  vessel,  though  the  number  of  the  latter 
is  also  affected  by  the. temperature. 

Test  for  Chlorine.  —  Solutions  required:  1.  Standard 
silver-nitrate  solution.  To  1  litre  of  pure  distilled  water  add 
4.788  grammes  of  pure  silver  nitrate  (AgNO3).  One  cubic 
centimetre  of  this  solution  is  equivalent  to  1  milligramme  of 
chlorine.  2.  Potassium-chromate  solution.  A  10-per-cent. 
solution  of  potassium  chromate  (K2CrO4)  in  distilled  water 
free  from  chlorine. 

Process:  To  100  c.  c.  of  the  water  to  be  tested  add  a  few 


THE   EXAMINATION    OF   WATER.  425 

drops  of  the  potassium-chromate  solution,  and  then  run  in  the 
silver-nitrate  solution  from  a  graduated  burette,  adding  it  drop 
by  drop  and  stirring  the  water  continually  with  a  glass  rod. 
Continue  until  a  faint  but  permanent  orange-red  tint  has  been 
produced,  showing  that  all  the  chlorine  has  combined  with  the 
silver,  the  persisting  reddish  tint  being  due  to  silver  chromate. 
The  number  of  cubic  centimetres  of  silver-nitrate  solution  used 
indicate  the  number  of  milligrammes  of  chlorine  in  100  c.  c.  of 
the  water,  or  the  parts  per  100,000 ;  this  multiplied  by  10  gives 
the  number  of  milligrammes  of  chlorine  in  1  litre,  or  parts  per 
million.  If  the  water  contain  but  little  chlorine,  the  test  will 
be  more  accurate  if  250  c.  c.  of  the  water  be  first  evaporated 
over  a  water-bath  to  about  50  c.  c.  before  proceeding  as 
above:  four  times  the  result  will  then  give  the  number  of  milli- 
grammes of  chlorine  in  1  litre.  Should  it  be  desired  to  express 
the  proportion  in  terms  of  sodium  chloride,  multiply  the  result, 
obtained  as  above,  by  1.648;  or  make  up  the  silver-nitrate  solu- 
tion by  adding  2.905  grammes  to  the  litre,  each  cubic  centimetre 
of  this  solution  being  then  equal  to  1  milligramme  of  sodium 
chloride. 

Test  for  Nitrates. — Solutions  required  :  1.  Phenol-sul phonic 
acid.  To  37  c.  c.  of  strong  sulphuric  acid  add  6  grammes  of 
pure  carbolic  acid  and  3  c.  c.  of  distilled  water.  2.  Standard 
potassium-nitrate  solution.  Add  0.722  gramme  of  fused  potas- 
sium nitrate  (KNO3)  to  1  litre  of  distilled  water.  Each  cubic 
centimetre  of  this  contains  T^  milligramme  of  nitrogen.  The 
water  used  in  making  these  solutions  must  be  free  from  nitrates. 

Process:  Evaporate  10  c.  c.  of  the  water  to  be  tested  (or 
25  c.  c.  if  it  is  presumably  low  in  nitrates)  just  to  dryness. 
This  is  best  done  over  a  water-bath.  Add  1  c.  c.  of  phenol- 
sulphonic  acid,  stir  with  a  glass  rod,  add  1  c.  c.  of  distilled 
water  and  3  drops  of  strong  sulphuric  acid ;  warm  the  dish, 
add  about  25  c.  c.  of  distilled  water,  then  ammonia  to  excess, 
and  dilute  with  distilled  water  to  exactly  100  c.  c.  Treat  1  c.  c. 
of  the  standard  potassium-nitrate  solution  in  exactly  the  same 


426  TEXT-BOOK    OF    HYGIENE. 

manner  and  compare  the  tints  produced.  Dilute  the  darker  of 
the  two  with  distilled  water  until  the  tints  match  exactly,  and 
calculate  the  amount  of  nitrogen  present  as  nitrates  in  the 
water  being  examined  from  the  amount  of  dilution  necessary. 
Example :  The  tint  from  the  1  c.  c.  of  standard  potassium- 
nitrate  solution  is  the  darker  and  needs  an  addition  of 
25  c.  c.  more  water  before  it  matches  the  other.  Therefore, 
125  :  100  : :  0.1  :  x  =  0.08, — the  number  of  milligrammes  of 
nitrogen  existing  as  nitrates  in  the  10  c.  c.  of  water  tested.  The 
test  depends  upon  the  conversion  of  the  phenol-sulphonic  acid 
into  picric  acid  by  the  nitrates  and  the  subsequent  formation  of 
ammonium  picrate,  which  gives  a  yellow  tint  to  the  water. 
The  amount  of  picric  acid  and  picrate  formed  is  exactly  propor- 
tional to  the  quantity  of  nitrates  present. 

Test  for  Nitrites. — Solutions  required:  1.  Sulphanilic  acid. 
Dissolve  0.5  gramme  of  sulphanilic  acid  in  150  c.  c.  of  dilute 
acetic  acid  (sp.  gr.  104).  2.  Naphthylamine  acetate.  Boil 
0.1  gramme  of  solid  naphthylamine  in  20  c.  c.  of  distilled  Avater, 
filter  through  a  plug  of  washed  absorbent  cotton  and  mix  the 
filtrate  with  180  c.  c.  of  dilute  acetic  acid.  3.  Standard  sodium- 
nitrite  solution.  Dissolve  0.275  gramme  of  pure  silver  nitrite 
in  pure  water,  add  a  dilute  solution  of  pure  sodium  chloride  till 
precipitate  ceases  to  form  and  dilute  to  250  c.  c.  with  pure  water. 
For  use,  dilute  10  c.  c.  of  this  solution  to  100  c.  c.,  each  cubic 
centimetre  of  the  latter  dilute  solution  containing  0.01  milli- 
gramme of  nitrogen.  Keep  the  stronger  solution  in  the  dark 
when  not  in  use,  and  make  up  the  dilute  solution  anew  each 
time.  All  water  used  in  these  solutions  must  be  free  from 
nitrites ;  likewise  all  water  used  for  dilution  in  the  test. 

Process  :  Measure  25  c.  c.  of  the  water  to  be  examined  into 
a  Nessler  tube  or  large  test-tube,  add  2  c.  c.  each  of  the  sulphan- 
ilic acid  and  naphthylamine-acetate  solutions,  using  a  separate 
pipette  for  each.  In  a  similar  tube  dilute  1  c.  c.  of  the  standard 
sodium-nitrite  solution  (dilute)  to  25  c.  c.  witli  nitrite-free  dis- 
tilled water,  and  add  the  same  quantity  of  the  above  reagents  to 


THE   EXAMINATION    OF   WATER.  427 

it.  Compare  the  colors  at  the  end  of  five  minutes,  and  esti- 
mate the  amount  of  nitrites  by  diluting  the  darker  solution  till 
it  matches  the  lighter,  just  as  was  done  in  testing  for  nitrates. 
The  foregoing  test  is  a  very  delicate  one,  and  gives  the  quantity 
of  nitrogen  present  as  nitrites,  which  should  not  be  over  a  trace. 

Test  for  Free  and  Albuminoid  Ammonia.  Wanklyn's 
Method. — Solutions  required  :  1.  Standard  ammonium-chloride 
solution.  Dissolve  0.382  gramme  pure  dry  ammonium  chloride 
(NH4C1)  in  100  c.  c.  ammonia- free  water.  Each  cubic  centi- 
metre of  the  dilute  solution  contains  0.01  milligramme  of 
nitrogen.  2.  Alkaline  potassium-permanganate  solution.  Dis- 
solve 200  grammes  of  potassium  hydrate  (KI1O)  in  sticks,  and 
8  grammes  of  potassium  permanganate  in  1  litre  of  distilled 
water.  Evaporate  to  about  750  c.  c.  to  drive  off  any  ammonia 
present,  and  make  up  to  1  litre  again  with  ammonia-free 
water.  To  make  ammonia-free  water,  add  about  1  grain  sodium 
carbonate  to  the  litre  of  distilled  water,  and  boil  till  about 
one-fourth  is  evaporated.  3.  Nessler's  reagent.  Dissolve  35 
grammes  potassium  iodide  (KI)  in  100  c.  c.  of  distilled  water, 
and  17  grammes  mercuric  chloride  (IIgCl2)  in  300  c.  c.  of 
water;  add  the  mercuric-chloride  solution  to  the  potassium 
iodide  until  a  permanent  precipitate  is  formed.  Then  dilute 
with  a  20-per-cent.  solution  of  sodium  hydrate  (NallO)  to  1000 
c.  c. ;  add  mercuric-chloride  solution  till  a  permanent  precipitate 
again  forms,  and  allow  to  stand  until  clear.  This  reagent  gives 
a  brown  or  yellowish-brown  coloration  if  ammonia  .be  present 
in  water,  and  improves  on  keeping. 

Process :  Place  500  c.  c.  of  the  water  to  be  examined  in  a 
retort,  connect  with  a  condenser,  and  boil  gently  so  that  the 
water  may  distil  over  slowly.  The  retort  and  condenser  should 
have  been  thoroughly  rinsed  with  ammonia-free  water.  Collect 
the  distillate,  50  c.  c.  at  a  time,  in  Ncssler  tubes,  add  2  c.  c.  of 
Nessler's  reagent  to  each  50  c.  c.  and  determine  the  amount  of 
ammonia  or  nitrogen  in  each,  as  follows :  Place  in  another 
Nessler  tube  50  c.  c.  ammonia-free  water  and  2  c.  c.  Nessler's 


428  TEXT-BOOK   OF   HYGIENE. 

reagent ;  run  in  from  a  burette  the  standard  ammonium-chloride 
solution  until  the  color  exactly  matches  that  of  the  first  50  c.  c. 
of  the  distillate.  Repeat  the  process  with  each  50  c.  c.  of  dis- 
tillate until  the  test  shows  that  no  more  ammonia  is  coming 
over  from  the  retort.  The  total  amount  of  ammonium-chloride 
solution  used  indicates  the  ^total  amount  of  nitrogen  of  the  free 
ammonia.  Usually  all  the  free  ammonia  will  come  over  in  the 
first  150  c.  c.  or  200  c.  c.  of  distillate.  Compare  the  colors  by 
looking  down  through  the  tube  upon  a  white  surface.  If  the 
first  50  c.  c.  give  a  precipitate  with  the  Nessler  reagent,  it  must 
be  diluted  and  the  amount  of  nitrogen  estimated  from  the 
diluted  distillate.  The  free  ammonia  being  all  determined, 
allow  the  retort  to  cool  and  add  to  the  water  remaining  in  it  50 
c.  c.  of  the  alkaline-permanganate  solution.  This  converts  a 
certain  proportion  of  the  nitrogenous  organic  matter  into  am- 
monia. Distil  as  before,  estimating  the  amount  of  nitrogen  in 
each  50  c.  c.  of  the  distillate,  until  no  more  ammonia  comes 
over.  The  amount  of  ammonium-chloride  solution  thus  used 
will  indicate  the  nitrogen  of  albuminoid  ammonia ;  and  the 
total  amount  of  ammonium-chloride  solution  used  in  the  whole 
process  gives  the  nitrogen  of  the/?*ee  and  albuminoid  ammonia 
in  the  500  c.  c.  of  water. 

Tests  for  Hardness. — Solutions  required  :  1.  Soap  solution. 
Dissolve  about  10  grammes  of  Castile  or  soft  soap  in  1  litre  of 
weak  (35  per  cent.)  alcohol.  2.  Standard  lime  solution.  Dis- 
solve 1.11  grammes  pure  calcium  chloride  in  1  litre  of  distilled 
water.  One  c.  c.  of  this  solution  is  equivalent  to  1  m.  g.  of 
calcium  carbonate  (CaCO3).  Process  :  First,  find  how  much  of 
the  soap  solution  is  needed  to  make  a  lather  with  100  c.  c.  of 
distilled  water,  as  follows :  Place  the  water  in  a  flask  holding 
about  250  c.  c.  and  run  in  the  soap  solution  from  a  burette,  a 
few  drops  at  a  time,  corking  and  shaking  the  flask  well  after 
each  addition.  The  lather  should  have  a  depth  of  about  one- 
fourth  of  an  inch,  and  should  be  permanent  for  at  least  five 
minutes.  Then  standardize  the  soap  solution  by  diluting  5  c.  c. 


THE   EXAMINATION   OF   WATER.  429 

of  the  standard  lime  solution  to  100  c.  c.  with  distilled  water 
and  finding  how  many  cubic  centimetres  of  the  soap  solution 
are  necessary  to  make  a  permanent  lather  with  it.  This 
quantity,  less  the  number  of  cubic  centimetres  needed  to  make 
a  lather  with  the  100  c.  c.  of  distilled  water,  represents  the 
amount  of  soap  solution  that  will  neutralize  5  m.  g.  of  cal- 
cium carbonate  or  its  equivalent.  Lastly,  determine  in  the 
same  way  the  number  of  cubic  centimetres  of  soap  solution 
necessary  to  make  a  permanent  lather  with  100  c.  c.  of  the 
water  to  be  examined;  subtract  the  quantity  necessary  for  100 
c.  c.  distilled  water  and  estimate  the  amount  of  calcium  carbon- 
ate or  its  equivalents  present,  as  follows :  For  example,  it  takes 
2  c.  c.  of  soap  solution  to  make  a  lather  with  the  distilled  water 
and  12  c.  c.  with  the  diluted  lime  solution.  Then,  12  —  2  — 
10  c.  c.  —  5  m.  g.  calcium  carbonate,  and  each  cubic  centimetre 
of  the  soap  solution  —  0.5  c.  c.  of  the  standard  lime  solution, 
or  0.5  m.  g.  calcium  carbonate.  Consequently,  if  100  c.  c.  of 
the  water  examined  require  17  c.  c.  of  soap  solution,  it  must 
contain  (17  —  2)  X  0.5  —  7.5  m.  g.  calcium  carbonate  or  its 
equivalent,  and  1  litre  of  the  water  contains  75  m.  g.  calcium 
carbonate. 

Testa  for  Lead,  Copper,  and  Iron. — To  50  or  100  c.  c.  of 
the  water  in  a  white  porcelain  dish,  or  in  a  tall  glass  jar,  over 
white  paper,  add  a  few  drops  of  ammonium  sulphide, — (NH4)2S. 
A  dark  coloration  or  precipitate  indicates  the  presence  of  either 
lead,  copper,  or  iron,  due  to  the  formation  of  the  respective 
sulphide.  Then  add  a  few  drops  of  hydrochloric  acid  (HC1). 
If  the  color  disappear,  iron  only  is  present ;  if  it  persist,  lead 
or  copper  is  present.  In  the  latter  case,  add  a  few  drops  of 
acetic  acid  and  about  1  c.  c.  of  a  strong  solution  of  pure  potas- 
sium cyanide.  If  the  color  disappear,  it  is  due  to  copper ;  if  it 
remain,  lead  is  present.  If  lead  only  is  present  in  the  water, 
the  above  test  will  detect  TV  grain  per  gallon.  The  above  test 
may  be  corroborated  as  follows :  Partly  fill  two  test-tubes  with 
the  original  water ;  to  one  add  a  little  potassium-chromate  solu- 


430  TEXT-BOOK    OF    HYGIENE. 

tion ;  an  opacity  and  the  deepening  of  the  color  to  a  canary 
yellow  indicates  lead.  To  the  second  add  a  drop  of  dilute 
hydrochloric  acid  and  a  few  drops  of -potassium-ferrocyanide 
solution ;  a  blue  color  indicates  iron,  either  ferrous  or  ferric ;  a 
bronze  or  a  mahogany-red  color  indicates  copper.  Quantitative 
tests  for  the  above  metals  may  be  made  by  making  standard 
solutions  of  the  respective  elements,  treating  a  measured  quan- 
tity of  the  original  water  with  the  proper  reagent,  as  indicated, 
and  comparing  the  color  produced  with  that  given  by  a  definite 
quantity  of  the  respective  standard  solution. 

Test  for  Phosphates. — Solution  required,  ammonium  molyb- 
date:  Dissolve  10  grammes  of  molybdic  anhydride  in  41.7  c.  c. 
of  ammonia  (NH4HO), — sp.  gr.  0.96, — and  pour  slowly  into  125 
c.  c.  of  nitric  acid  (HNO3), — sp.  gr.  1.20 ;  allow  to  stand  in  a 
warm  place  for  several  days  till  clear.  Process  :  Slightly  acidify 
500  c.  c.  of  the  water  with  nitric  acid,  evaporate  to  about  50  c.  c., 
add  a  few  drops  of  ferric  chloride  (Fe2Cl6)  and  ammonia  in 
slight  excess.  Filter,  dissolve  the  precipitate  in  the  smallest 
possible  quantity  of  nitric  acid,  and  evaporate  to  5  c.  c.  Heat 
nearly  to  boiling ;  add  2  c.  c.  of  ammonium-molybdate  solu- 
tion ;  keep  solution  warm  for  one-half  hour.  If  there  is  an 
appreciable  quantity  of  precipitate,  collect  it  on  a  small,  weighed 
filter-paper,  wash  with  distilled  water,  dry  at  100°  F.,  and 
weigh.  The  weight  of  the  precipitate  multiplied  by  0.05  gives 
the  amount  of  phosphates  as  PO4  in  the  500  c.  c.  of  water. 

In  the  bacteriological  examination  of  water,  1  c.  c.,  or  a 
definite  fractional  part  thereof,  of  the  water  is  to  be  added  to  a 
little  sterilized  nutrient  gelatin,  heated  just  enough  to  liquefy  it, 
the  whole  shaken  to  thoroughly  mix  it,  and  then  cooled  in  an 
even  film  on  the  interior  of  the  test-tube  (Esmarch's  roll-cult- 
ure) or  poured  out  upon  sterilized  glass  plates  or  into  Petri 
dishes.  Or,  as  Prof.  Leffmann  suggests,  fiat,  rectangular  bottles, 
of  8  or  10  ounces'  capacity,  may  be  used  instead  of  test-tubes. 
Sufficient  nutrient  gelatin  is  placed  in  eacli  to  cover  one  of  the 
flat  sides  with  a  thin  film,  and  the  bottle  stoppered  and  steril- 


THE   EXAMINATION   OF   FOOD.  431 

ized.  Then,  when  needed,  the  gelatin  is  gently  melted,  the 
measured  quantity  of  water  introduced  and  mixed  with  the 
gelatin,  and  the  bottle  placed  on  its  side  until  the  gelatin  cools. 
Within  a  short  time  colonies  develop  from  the  micro-organisms 
thus  fixed  in  the  gelatin,  and  from  these  colonies  pure  cultures 
may  be  made  of  the  respective  species,  and  further  experiments 
and  study  carried  on. 

It  must  always  be  remembered  that,  in  collecting  samples 
of  water  for  bacteriological  examination,  great  care  must  be  ob- 
served to  avoid  accidental  contamination  of  the  culture-media, 
etc.,  by  extraneous  organisms.  Where  possible,  the  inoculations 
should  be  made  at  the  place  where  the  samples  of  water  are  col- 
lected, the  water  being  taken  up  by  means  of  sterilized  pipettes 
and  measured  at  once  into  the  sterilized  gelatin  tubes  or  bottles. 
If  this  cannot  be  done,  the  water  should  be  collected  in  well- 
sterilized,  glas's-stoppered  bottles.  These  should  be  washed 
externally,  submerged,  unstoppered,  filled  and  restoppered, — all 
below  the  surface, — and  then  transferred  to  the  laboratory  and 
the  inoculations  made  as  soon  as  possible,  packing  them  in  ice 
if  the  distance  be  great  or  there  is  any  cause  for  delay,  in  order 
to  prevent  the  too  rapid  multiplication  of  certain  of  the  organ- 
isms and  the  disappearance  of  others. 

THE   EXAMINATION   OF   FOOD. 

It  would  be  manifestly  inadvisable  to  attempt  to  detail, 
within  the  limits  of  this  chapter,  the  methods  for  the  determina- 
tion of  the  purity  and  healthfulness  of  the  many  articles  of  food 
that  make  up  the  daily  dietaries  of  the  people  at  large ;  but 
since  occasions  are  constantly  arising  when  it  is  desirable  to 
know  something  of  the  condition  of  certain  food-stuffs  which  are 
used  by  practically  every  one,  and  which  are  especially  liable 
to  sophistication  or  adulteration,  the  following  notes  are,  there- 
fore, added  as  being  within  the  scope  of  the  chapter : — 

MILK. — Good  milk  should  be  ivory-white  in  color,  opaque, 
of  neutral  or  slightly-alkaline  reaction,  and  should  have  no 


432  TEXT-BOOK   OF   HYGIENE. 

sediment  nor  any  unusual  taste  or  odor.  The  specific  gravity 
should  be  1029  or  above;  the  proportion  of  cream,  from  10  to 
40  per  cent,  by  volume ;  the  fats,  3  per  cent,  or  more,  and  the 
total  solids  12.5  per  cent,  or  more. 

The  color  is  enriched  by  a  high  percentage  of  cream,  but 
too  rich  a  color  or  one  with  a  reddish  or  yellowish  tint  may  in- 
dicate the  addition  of  annatto.  A  poor  color  indicates  that  the 
milk  is  deficient  in  fat,  and  may  be  due  to  skimming  or  water- 
ing, or  both,  but  a  peculiar  blue  color  is  sometimes  produced  by 
the  growth  of  a  certain  fungus  in  the  milk.  The  lessening  of 
fat  also  tends  to  make  the  milk  translucent  and  less  opaque. 

An  acid  reaction,  unless  very  slight,  indicates  "  souring  " 
of  the  milk  or  the  addition  of  some  preservative,  such  as  saly- 
cylic  or  boric  acid ;  while  a  strongly-alkaline  reaction  points  to 
the  addition  of  some  substance  like  chalk,  sodium  carbonate, 
etc.,  to  increase  the  specific  gravity.  Such  addition  is  verified 
by  a  high  percentage  of  total  solids  and  by  the  effervescence  of 
the  latter  upon  the  addition  of  a  drop  or  two  of  hydrochloric 
acid. 

The  specific  gravity  is  determined  by  means  of  the  lactom- 
eter, in  using  which  corrections  must  be  made  for  the  tempera- 
ture if  the  latter  varies  much  from  60°  F.,  the  standard.  The 
specific  gravity  is  slightly  raised  by  skimming  the  milk,  since 
the  cream  is  lighter  than  the  whole  milk,  and,  theoretically,  a 
very  high  percentage  of  cream  tends  to  lower  the  specific 
gravity ;  but,  in  reality,  a  milk  rich  in  cream  is  also  rich  in 
other  solids  that  keep  the  specific  gravity  high  or,  at  least, 
normal. 

The  percentage  of  cream  is  determined  by  the  creamome- 
ter  (see  page.  101),  which  should  be  covered  and  in  which  the 
milk  should  stand  for  eight  or  ten  hours. 

The  principal  sophistications  of  milk  are  by  watering,  skim- 
ming, the  addition  of  solids  to  increase  the  specific  gravity  or  to 
act  as  preservatives  or  to  mask  "  souring,"  and  the  addition  of 
annatto  and  the  like  to  enrich  the  color.  Watering  is  indicated 


THE   EXAMINATION   OF   FOOD.  433 

by  a  low  specific  gravity  and  by  a  low  percentage  of  cream  and 
of  total  solids.  Skimming  is  indicated  by  a  low  percentage  of 
cream  and  poor  color,  though  the  latter  may  be  disguised  by 
the  addition  of  annatto,  etc.  The  specific  gravity  will  be  very 
slightly  raised  by  the  skimming,  but  if  the  milk  has  been  both 
skimmed  and  watered  the  density  will  be  lowered. 

To  Determine  the  Percentage  of  Total  Solids. — Weigh  a 
small  evaporating-dish,  preferably  platinum.  Add  5  or  10  c.  c. 
of  milk,  and  weigh  the  dish  and  milk  to  get  the  weight  of 
milk.  Evaporate  to  dry  ness  over  a  water-bath,  completing  the 
drying  in  a  water-oven  until  there  is  no  further  loss  of  weight. 
Weigh  the  dish  and  contents  (total  solids) ;  subtract  the  weight 
of  dish  and  divide  by  the  weight  of  milk.  The  result  is  the 
percentage  of  total  solids. 

To  Determine  the  Percentage  of  Ash. — Ignite  the  total 
solids  over  the  naked  flame  until  all  black  specks  have  disap- 
peared. Cool  and  weigh.  Divide  the  weight  of  ash  by  weight 
of  milk.  The  result  is 'the  percentage  of  ash. 

To  Determine  the  Percentage  of  Fats. — Proceed  as  above 
with  10  c.  c.  of  milk  and  evaporate  till  the  residue  is  a  tena- 
cious pulp.  Extinguish  the  flame,  fill  the  dish  half-full  of 
ether,  and  stir  and  pound  the  residue  thoroughly  with  a  glass 
rod ;  filter  through  a  small  filter-paper,  reserving  the  filtrate ; 
add  more  ether  to  the  residue,  stir  as  before  and  filter,  repeating 
the  process  three  times,  or  till  the  residue  is  perfectly  white. 
Wash  filter-paper  well  with  ether,  and  evaporate  all  the  ether 
to  dryness.  Weigh  the  residue  (the  fat)  and  divide  by  the 
weight  of  milk.  Result :  percentage  of  fats. 

Test  for  Annatto. — A  percentage  of  cream  considerably 
lower  than  the  color  of  ntilk  would  indicate  justifies  the  sus- 
picion that  some  coloring  matter  has  been  used.  This  is  gen- 
erally annatto.  Coagulate  one  ounce  of  milk  with  a  few  drops 
of  acetic  acid,  and  heat ;  strain  and  press  out  excess  of  liquid 
from  curd.  Triturate  the  curd  in  a  mortar  or  dish  with  ether. 
Decant  the  ether  and  add  to  it  10  c.  c.  of  a  1-per-cent.  solution 


434  TEXT-BOOK   OF   HYGIENE. 

of  caustic  soda.  Shake  and  allow  to  separate  ;  pour  off  the 
upper  layer  into  a  porcelain  dish.  Put  in  two  small  discs  or 
strips  of  filter-paper.  Evaporate  gently  ;  annatto  will  dye  the 
discs  an  orange  or  buff  color.  Moisten  one  disc  with  dilute 
sodium  carbonate  to  fix  the  color.  Touch  the  other  disc  with  a 
drop  of  stannous  chloride  ;  annatto  will  give  a  rich  pink  color. 
This  test  is  sensitive  to  1  part  of  annatto  in  1000  of  milk,  and 
with  milk  in  any  condition. 

Test  for  Boric  Acid. — In  igniting  the  total  solids,  boric  acid, 
or  boron,  gives  a  greenish  tinge  to  flame.  Place  in  a  porcelain 
dish  one  drop  of  milk,  two  drops  of  strong  hydrochloric  acid, 
and  two  of  a  saturated  tincture  of  tumeric.  Dry  on  a  water- 
bath,  remove  as  soon  as  dry,  cool  and  add  one  drop  of  ammo- 
nia on  a  glass  rod.  A  slaty-blue  color,  changing  to  green,  is 
given  if  borax  is  present.  This  test  will  show  -j-oV'o  grain  of 
borax.  Less  will  give  the  green  color,  but  not  the  blue. 

BUTTER. — Good  butter  should  have  a  good  taste,  odor,  and 
color;  it  should  not  be  rancid,  and  should  not  contain  too 
much  water  or  salt,  nor  should  it  have  any  added  coloring 
matter.  The  average  composition  should  be  about  as  follows : 
Fat,  82  per  cent. ;  casein,  2  per  cent,  (not  over  3  per  cent.); 
ash  or  salts,  2  per  cent.;  water,  13  per  cent.;  milk-sugar,  1 
per  cent.  Butter-fat  is  a  compound  of  a  glycerin  with  certain 
fatty  acids,  some  of  them  volatile  and  soluble  in  hot  water, 
others  non- volatile  and  insoluble  in  hot  water. 

Oleo-margarine  consists  of  ordinary  animal  (or  vegetable) 
fats  melted,  strained,  cooled  with  ice,  worked  up  with  milk,  col- 
ored, and  salted.  These  fats  are  usually  beef  or  mutton,  lard 
or  cotton-seed,  palm-  or  cocoa-nut-  oil.  If  care  and  cleanliness 
are  observed  in  the  manufacture,  oleomargarine  is  not  harmful 
or  innutritions,  but  it  should  not  be  sold  as  butter. 

Fraud  is  to  be  detected  by  observing  the  difference  in 
composition  and  properties  of  the  fats.  The  following  table, 
from  Kenwood's  "  Hygienic  Laboratory,"  will  show  the  char- 
acteristic difference  in  the  fats  : — 


THE   EXAMINATION    OF   FOOD. 


435- 


BUTTEB-FAT. 

1 .  The  specific  gravity  is  very  rarely  be- 
low 910,  never  below  909.8. 

2.  The  soluble,  volatile  fatty  acids  aver- 
age between  6  and  7  per  cent.,  never  below 
4.5  per  cent. 

3.  The  insoluble  fatty  acids  form  about 
88  per  cent,  of  the  total  weight  of  butter- 
fat. 

4.  The  melting-point  of  the  fat  varies 
from  86°  to  94°  F. ;  is  usually  from  88° 
to  90°  F. 

5.  Is  readily  and  completely  soluble  in 
ether. 

6.  Under  the   microscope  pure   butter 
consists  of  a  collection  of  small  oil-glob- 
ules with   an  occasional  large  one.     No 
crystals,  except  when  the    fat  has  been 
melted. 


BEEF-FAT,  ETC. 
Is  never  above  904.5. 

Rarely  more  than  %  per  cent. ;  never 
above  %  per  cent. 

Generally  about  95  per  cent. 


Rarely,  if  ever,  above  82°  F. 


Less  so,  and  leaves  a  residue. 

The  contours  of  the  small  oil-globules 
are  less  distinct,  and  the  larger  ones  are 
more  numerous  and  irregular  in  size. 
Crystals  of  the  non-volatile  acids  are  often 
seen. 


To  Determine  the  Specific  Gravity. — Melt  a  quantity  of  the 
butter  in  a  beaker  on  a  water-bath  at  about  150°  F.  After  a 
time,  when  the  fat  is  perfectly  clear  and  transparent,  carefully  de- 
cant from  the  lower  stratum  of  water,  curd  and  salt  on  to  a  fine 
filter ;  collect  the  filtrate  and  pour  into  a  specific-gravity  bottle, 
which  has  been  previously  weighed,  both  when  empty  and  when 
filled  with  distilled  water  at  100°  F.  See  that  the  bottle  is 
exactly  full  of  the  fat ;  wipe  clean  and  weigh  when  the  tempera- 
ture is  as  near  100°  F.  as  possible,  because  solidification  soon 
begins  below  this  temperature.  Subtract  the  weight  of  the 
bottle,  divide  by  the  weight  of  the  water,  and  multiply  by  1000. 
The  result  is  the  specific  gravity. 

To  Find  the  Melting- Point. — Pour  a  little  melted  fat  into 
a  small  test-tube  (2"  x  J").  Partly  fill  two  beakers  of  unequal 
size  with  cold  water ;  place  the  test-tube  in  the  smaller  (taking 
care  to  allow  no  water  to  mix  with  the  fat),  and  the  smaller  in 
the  larger,  and  gently  heat  the  outer  beaker.  Suspend  a  ther- 
mometer in  the  smaller,  near  the  test-tube,  and  note  the  temper- 
ature when  the  fat  begins  to  melt.  This  is  the  melting-point. 

To  Determine  the  Percentage  of  Insoluble  (Non- Volatile) 
Fatty  Acids. — To  5  grammes  of  butter-fat  add  50  c.  c.  of  alcohol 


436  TEXT-BOOK   OF   HYGIENE. 

containing  2  grammes  of  caustic  potash  (KHO)  and  boil  gently 
for  fifteen  or  twenty  minutes  to  saponify  the  fat.  Dissolve  the 
soaps  thus  formed  in  150  to  200  c.  c.  of  water  and  decompose 
with  about  25  c.  c.  of  dilute  hydrochloric  acid.  The  separated 
fatty  acids  are  collected  upon  a  weighed  filter-paper,  washed 
with  2  litres  of  boiling  water,  dried  at  95°  to  98°  C.,  and  then 
weighed.  The  weight  of  these  insoluble  fatty  acids  should  not 
be  over  90  per  cent,  of  the  weight  of  the  butter-fat. 

FLOUR  AND  BREAD. — Wheat-flour  should  be  almost  but  not 
perfectly  white,  also  smooth  and  free  from  grit ;  it  should  have 
no  moldy  or  unpleasant  odor,  and,  unless  made  by  the  new 
process,  should  be  cohesive  when  lightly  compressed  in  the 
hand.  There  should  be  no  signs  of  parasites  or  fungi  under 
the  microscope.  The  proportion  of  gluten  should  be  more  than 
8  per  cent. ;  of  water,  less  than  18  per  cent.,  and  of  ash,  less 
than  2  per  cent. 

To  Determine  the  Percentage  of  Water  and  Ash. — In  a 
weighed  platinum  (or  porcelain)  dish  place  about  50  grammes 
of  flour,  weigh  and  dry  over  a  water-bath  for  an  hour  or  so ; 
then  complete  the  evaporation  in  a  water-oven  until  there  is  no 
further  loss  of  weight ;  weigh,  subtract  this  weight  less  the 
weight  of  the  dish  from  the  original  weight  of  the  flour ;  divide 
the  remainder,  the  weight  of  the  water,  by  the  original  weight 
of  the  flour.  The  result  is  the  percentage  of  water.  Then 
ignite  the  dried  flour  in  the  dish  and  incinerate  till  there  are  no 
longer  any  black  particles  and  only  the  ash  remains ;  cool, 
weigh,  and  divide  by  the  original  weight  of  the  flour.  The 
result  is  the  percentage  of  ash. 

To  Determine  the  Percentage  of  Gluten. — By  means  of  a 
glass  rod,  mix  a  weighed  quantity  of  flour  with  a  little  distilled 
water  into  a  stiff  dough  ;  then  repeatedly  wash  away  the  starch 
and  soluble  constituents,  kneading  the  dough  with  the  rod  or 
fingers  and  continuing  until  the  wash-water  conjes  away  clear ; 
the  gluten  and  a  small  amount  of  fat  and  salts  remain.  Spread 
out  on  a  weighed  dish  or  crucible-lid,  dry  in  a  water-oven,  and 


THE   EXAMINATION   OF   FOOD.  437 

weigh ;  divide  by  the  original  weight  of  the  flour.  The  result 
is  the  approximate  percentage  of  gluten.  The  gluten  should 
pull  out  into  long  threads,  otherwise  it  is  poor. 

An  excess  of  water  impairs  the  keeping-quality  and  lessens 
the  amount  of  nutriment  in  the  flour.  An  excess  of  ash  indi- 
cates the  addition  of  mineral  substances.  A  deficiency  of  gluten 
indicates  that  the  flour  is  not  pure  wheat-flour.  Parasites 
and  fungi  especially  affect  or  live  in  old  or  damp  and  inferior 
flour. 

To  Test  for  Mineral  Substances. — Shake  a  little  flour  in  a 
test-tube  with  some  chloroform,  and  allow  it  to  stand  for  a  few 
moments.  The  flour  floats  and  any  mineral  matter  sinks  to  the 
bottom,  when  it  can  be  removed  with  a  pipette  and  examined 
under  a  microscope. 

Wheat-bread  should  be  fairly  dry,  light,  and  spongy ;  clean 
and  nearly  white ;  of  pleasant  taste ;  not  sodden,  acid,  or 
musty ;  no  parasites  or  moldiness.  It  should  contain  no  flour 
other  than  wheat;  but  little,  if  any,  alum  ;  no  copper  sulphate ; 
and  should  not  yield  over  3  per  cent,  of  ash. 

Test  for  Alum. — Add  5  c.  c.  of  a  5-per-cent.  tincture  of 
logwood  and  5  c.  c.  of  a  1 5-per-cent.  solution  of  ammonium 
carbonate  to  25  c.  c.  of  water ;  soak  a  crumb  of  the  bread  in 
this  for  a  few  minutes ;  drain  and  gently  dry.  Alum  is  indi- 
cated by  a  violet  or  lavender  color,  its  absence  by  a  dirty-brown 
color  on  drying. 

Test  for  Copper  Sulphate. — Draw  a  glass  rod  dipped  in  a 
solution  of  potassium  ferrocyanide  across  a  cut  slice  of  the 
bread ;  copper  is  indicated  by  a  streak  of  brownish-red  color. 

Test  for  Ergot  in  Flour  or  Bread. — Add  liquor  potassse ; 
a  distinct,  herring-like  odor  (due  to  propylamine)  is  appreciable 
if  ergot  be  present. 

An  excess  of  water,  an  unnatural  whiteness,  and  a  low 
percentage  of  ash  in  bread  indicate  the  addition  of  rice.  Pota- 
toes give  an  increased  percentage  of  water  and  an  alkaline 
ash. 


438  TEXT-BOOK   OF   HYGIENE. 

[The  following  works  are  recommended  to  those  desiring 
fuller  details  of  the  foregoing  methods,  or  for  the  further  ex- 
amination of  these  subjects  : — 

Kenwood's  Hygienic  Laboratory. — Examination  of  Water  for  San- 
itary and  Technical  Purposes,  by  Leffmann  and  Beam. — Sanitary  Exam- 
inations of  Air,  Water,  and  Food,  by  Fox. — Parkes's  Practical  Hygiene. 
— Practical  Hygiene,  by  Coplin  and  Bevan.] 


QUESTIONS  TO  CHAPTER  XXII. 
THE  EXAMINATION  OF  AIR,  WATER,  AND  FOOD. 

Of  what  substances  in  the  atmosphere  may  it  be  necessary  at  times 
to  obtain  the  proportion  ?  How  is  the  proportion  of  aqueous  vapor  to 
be  determined  ?  What  causes  the  difference  in  the  readings  of  the  wet- 
and  dry-  bulb  thermometers,  and  what  tables  are  to  be  used  in  conjunc- 
tion with  them  ? 

How  may  the  presence  of  ozone  in  the  air  be  demonstrated  ?  Upon 
what  does  the  test  depend?  How  might  an  approximate  quantitative 
test  of  ozone  be  made  ? 

How  may  the  suspended  impurities  in  the  atmosphere  be  collected 
for  examination  ?  Which  method  requires  the  least  apparatus,  etc.  ? 
How  may  the  character  and  nature  of  the  suspended  particles  be  de- 
termined ?  How  may  a  quantitative  bacteriological  examination  be 
made?  What  are  some  of  the  advantages  of  Dr.  Dixon's  apparatus? 
Of  the  sugar-filter  method?  How  may  pure  cultures  of  micro-organisms 
in  the  air  be  obtained  ? 

How  may  the  quantity  of  organic  matter  in  the  air  be  determined  ? 
Why  do  we  determine  the  proportion  of  carbon  dioxide  in  the  air? 
What  is  Wolpert's  method  for  finding  the  percentage  of  this  gas,  and 
how  may  this  method  be  simplified  ?  Upon  what  does  this  test  depend  ? 
What  precautions  must  be  observed  in  making  the  test?  What  is  the 
Angus  Smith  method  for  determining  the  proportion  of  carbon  dioxide? 
How  may  it  be  improved?  What  is  the  use  of  the  phenol  phthaleine  in 
the  solution  ?  How  is  the  percentage  of  carbon  dioxide  calculated  ? 
How  is  the  alkaline  solution  to  be  prepared? 

Upon  what  does  Pettenkofer's  method  depend?  What  apparatus 
and  reagents  are  required?  Why  must  the  lime-water  be  standardized 
each  time?  What  is  the  value  of  the  oxalic-acid  solution?  What  are 
some  good  indicators  to  use  in  this  test  ?  Why  is  just  twice  the  volume 
of  lime-water  introduced  into  the  bottle  that  is  afterward  taken  from  it 
and  tested  ?  What  are  some  of  the  advantages  and  disa'd vantages  of 
baryta-water  in  comparison  with  lime-water? 

How  may  the  quantity  of  ammonia  in  the  atmosphere  be  determined  ? 
How  may  the  presence  of  other  gases  be  shown  ?  What  is  the  usual  test 
for  carbon  monoxide?  Upon  what  is  Yogel's  test  based?  Is  it  a  deli- 
cate one  ?  Why  is  it  usually  not  necessary  to  make  a  quantitative  ex- 
amination of  the  carbon  monoxide? 

What  care  should  be  observed  in  the  collection  of  water  for  ex- 
amination? How  much  will  be  necessary  for  the  customary  tests? 
What  notes  should  be  made  at  the  time  of  collection? 

What  tests  require  the  previous  clearing  of  the  water?  How  are 
the  tests  for  color  and  turbidity  made?  For  smell?  What  indicates 

(439) 


440  QUESTIONS   TO    CHAPTER    XXII. 

the  degree  of  aeration?  What  metallic  impurities  may  give  a  taste  to 
the  water  ?  What  information  as  to  the  source  or  purity  of  a  water  may 
sometimes  be  given  by  the  smell  ? 

What  are  the  solutions  needed  in  the  quantitative  test  for  chlorine  ? 
What  is  the  strength  of  each,  and  what  is  the  relation  of  the  silver- 
nitrate  solution  to  chlorine?  What  is  the  use  of  the  potassium-chroniate 
solution?  How  may  the  result  be  expressed?  What  solutions  are  used 
in  testing  for  nitrates  quantitatively?  Upon  what  does  this  test  de- 
pend? What  does  the  depth  of  color  indicate?  What  precautions 
must  be  observed  in  testing  for  nitrites  ?  Is  the  test  a  delicate  one? 

In  the  test  for  free  and  albuminoid  ammonia,  what  is  the  function 
of  the  ammonium-chloride  solution?  Of  the  potassium-permanganate 
solution?  What  part  of  the  distillate  contains  most  of  the  free  am- 
monia? When  is  it  evident  that  the  water  contains  no  more  ammonia? 

In  testing  for  hardness,  why  is  a  standard  lime  solution  necessary  ? 
What  should  be  the  characteristics  of  the  lather  produced  by  the  soap 
solution  ?  Why  is  alcohol  used  as  a  solvent  for  the  soap  ?  What  is  the 
underlying  principle  of  this  test? 

How  may  lead,  copper,  or  iron  be  detected  in  water?  How  may 
you  distinguish  between  the  respective  sulphides  of  the  above  metals? 
How  may  the  above  test  respecting  any  one  of  the  metals  be  corrobo- 
rated ?  How  delicate  is  the  test,  as  regards  lead  ?  How  might  a  quan- 
titative determination  of  these  metals  be  made?  What  is  the  principal 
reagent  used  in  the  test  for  phosphates  ? 

How  may  a  bacteriological  examination  of  water  be  made  ?  Where 
is  it  best  to  make  the  inoculations,  and  why  ?  What  precautions  must 
always  be  observed  in  such  examinations? 

What  are  some  of  the  characteristics  of  good  milk?  What  may 
affect  its  color  ?  Its  reaction  ?  Its  specific  gravity  ?  How  is  it  usually 
sophisticated  or  adulterated  ?  How  is  the  percentage  of  total  solids  de- 
termined ?  Of  fats?  What  would  a  high  percentage  of  ash  indicate? 
Give  a  test  for.annatto.  For  boric  acid. 

WThat  are  the  characteristics  of  good  butter?  What  is  the  differ- 
ence between  it  and  oleo-margarine  and  similar  compounds?  What  two 
kinds  of  fatty  acids  does  butter-fat  contain  ?  What  are  some  of  the 
distinctions  between  butter-fat  and  beef-fat  or  mutton-fat?  How  is  the 
specific  gravity  of  buttei--fat  determined?  The  melting-point?  The 
percentage  of  insoluble  fatty  acids  ? 

What  are  some  of  the  properties  of  good  wheat-flour  ?  Of  wheaten 
bread?  How  is  the  percentage  of  gluten  in  flour  determined?  The 
presence  of  added  mineral  substances?  What  does  a  low  percentage 
of  gluten  indicate?  In  what  kind  of  flour  are  parasites,  etc.,  found  ? 
What  is  a  test  for  alum  in  bread?  Should  bread  contain  any  alum? 
What  flours  or  starches  may  be  used  to  sophisticate  wheat-flour? 


CHAPTER  XXIII. 
QUAKANTINE. 

(By  WALTER  WYMAN,  M.D.,  Surgeon-General  United  States  Marine-Hospital  Service,  and 
H.  D.  GEDDINGS,  M.D.,  Passed  Assistant  Surgeon  Marine-Hospital  Service.) 

BY  quarantine  is  meant  the  adoption  of  restrictive  measures 
to  prevent  the  introduction  of  diseases  from  one  country  or 
locality  into  another.  The  term  itself  conveys  no  definite  idea, 
being  derived  through  the  Italian  from  the  Latin  "  quadraginta," 
meaning  "  forty  "  and  implying  forty  days, — the  period  of  deten- 
tion imposed  on  vessels  by  the  first  quarantines  established  at 
Venice  in  1403.  The  old  significance  of  the  term  is  entirely' 
lost  in  its  present  application,  which  is  quite  general.  Thus, 
besides  regular  maritime  quarantine,  mention  is  often  made  of 
land,  railroad,  cattle,  shot-gun,  house,  and  even  room  quaran- 
tines. 

The  name  of  a  disease  or  article  of  merchandise  may  be 
used  in  prefix,  as  in  "  yellow-fever  quarantine,"  small-pox, 
cholera,  or  rag  quarantine.  Moreover,  quarantines  are  described 
as  properly  beginning  at  the  port  of  departure,  and  as  quaran- 
tines of  inspection  only,  the  fumigation  and  detention  being 
imposed  at  some  neighboring  station.  The  term,  therefore,  is 
applied  not  only  to  establishments,  but  indifferently  to  persons, 
animals,  diseases,  localities,  and  measures. 

There  is  need  of  a  clear  understanding  with  regard  to  the 
term,  for  when,  as  occasionally,  quarantine  is  ridiculed,  or  the 
assertion  is  made  that  the  English  disbelieve  in  quarantine,  a 
wrong  impression  will  be  received,  unless  it  is  understood  that 
only  particular  and  obsolete  forms  of  quarantine  are  meant, 
and  not  quarantine  in  the  broad  sense  just  mentioned. 

The  subject  admits  of  two  natural  divisions — maritime  and 
land  quarantine  ;  but  before  describing  them  attention  is  called 
to  the  following  table,  containing  a  list  of  diseases  that  are  ordi- 
narily found  in  official  quarantine  proclamations  : — 

(441) 


442 


TEXT-BOOK   OF    HYGIENE. 


TABLE  XXXII. 

QUABANTINABLE   DISEASES. 


DISEASE. 

PERIOD  OF  INCUBATION,  IN  DAYS. 

Shortest. 

Longest. 

Usual. 

Authority  and  Remarks. 

3 
1 

2 
1 
5 

7 
2 
7 
1 
5 
1 

8 
11 

14 
21 

20 
14 

10 
28 
weeks. 
7 
10 

3  to  5 
»i 

2  to    4 
5  to  14 
10 
10 
2  to  5 
21 
4  to  7 
6 
5 

Kitisato. 
Da  Costa,       Bavtholow, 
Geddings. 
Bartholow. 
Bristow. 
Da  Costa. 
Da  Costa. 
Bartholow. 
Bartholow. 
Da  Costa. 
Bartholow. 
Bartholow. 
Undetermined. 

Yellow  fever  .    .    . 
Cholera  

Typhus  fever  .     .     . 
Small-pox  .... 

Diphtheria.     .     .     . 
Typhoid  fever     .     . 
Scarlet  fever  .     .     . 
Relapsing  fever  .     . 
Den°rue  

Leprosy  

The  above  list  illustrates  the  growth  of  the  sanitary  idea 
and  belief  in  quarantine.  For  many  years,  as  now  at  some 
ports,  the  list  was  limited  to  yellow  fever,  typhus,  cholera,  and 
small-pox.  It  was  thus  limited  at  Boston  prior  to  1881,  since 
which  date  diphtheria,  scarlet  fever,  typhoid  fever,  and  measles 
have  been  added.  The  statutes  of  New  York  define  as  quaran- 
tinable  "  yellow  fever,  measles,  cholera,  typhus  or  ship  fever, 
small-pox,  scarlatina,  diphtheria,  relapsing  fever,  and  any  dis- 
ease of  a  contagious,  infectious,  or  pestilential  character,  which 
shall  be  considered  by  the  health  officer  dangerous  to  the 
public  health." 

At  Gibraltar,  the  English  sanitary  authorities  include 
dengue  and  epidemic  rose-rash  among  the  diseases  subject  to 
their  quarantine  regulations.  t 

The  most  recent  addition  to  the  list  in  this  country  is 
leprosy,  to  prevent  the  introduction  of  which,  and  in  accord- 
ance with  a  resolution  of  the  American  Public  Health  Associa- 
tion, a  prohibitory  circular  was  issued  by  the  Surgeon-General 
of  the  Marine-Hospital  Service,  December  23,  1889. 


FOREIGN   QUARANTINE.  443 

Other  diseases  which  may  properly  call  for  quarantine  are 
mumps,  whooping-cough,  chicken-pox,  epidemic  dysentery, 
glanders,  tetanus,  beriberi,  epidemic  influenza,  and  pulmonary 
tuberculosis. 

Influenza  may  be  considered  quarantinable  under  certain 
circumstances,  a  successful  quarantine  being  reported  by  Dr. 
Trudeau,  whose  cottage  sanitarium,  in  the  Adirondacks,  New 
York,  was  thus  kept  exempt  during  the  epidemic  of  1890. 

With  regard  to  pulmonary  tuberculosis  the  ground  is  taken 
by  the  writer  that  this  disease,  at  least  among  immigrants,  should 
be  excluded  from  the  United  States  by  quarantine. 

FOREIGN  QUARANTINE. 

The  object  of  maritime  quarantine  being  protection  against 
the  importation  of  contagious  or  infectious  disease,  chiefly  from 
abroad,  through  the  medium  of  vessels,  their  crews,  passengers, 
and  cargoes,  it  is  most  logical  that  restrictive  measures  should 
begin  at  the  port  of  departure.  Following  are  the  regulations 
prepared  by  the  Supervising  Surgeon-General  United  States 
Marine-Hospital  Service,  and  promulgated  by  the  Secretary  of 
the  Treasury,  April  26,  1894.  All  quarantine  regulations  are 
subject  to  occasional  revision  under  the  Act  of  Congress  ap- 
proved February  15,  1893. 

U.  S.  QUARANTINE  REGULATIONS  TO  BE  OBSERVED  AT  FOREIGN  PORTS 

AND  AT  SEA. 

ARTICLE  I. — BILLS  OF  HEALTH. 

Par.  1.  Masters  of  vessels  departing  from  any  foreign  port  for  a 
port  in  the  United  States  must  obtain  a  bill  of  health  in  duplicate,  signed 
by  the  proper  officer  or  officers  of  the  United  States,  as  provided  for  by 
law. 

The  following  f»rm  is  prescribed : — 
Par  2.  Bill  of  health : 

Form  No.  1931  a. 

UNITED   STATES   BILL   OF  HEALTH. 

Name  of  vessel, .  Nationality, .  Rig, .  Master, .  Ton- 
nage, gross,  ;  net,  .  Iron  or  wood.  Number  of  compartments  for  cargo, 

;  for  steerage  passengers, ;  for  crew, . 

Name  of  medical  officer, . 


444  TEXT-BOOK   OF   HYGIENE. 


Number  of  officers, . 

Number  of  crew,  including  petty  officers, . 

Number  of  passengers,  cabin, . 

Number  of  passengers,  steerage, . 

Number  of  persons  on  board,  all  told, . 

Port  of  departure, . 

Where  last  from, . 

Number  of  cases  of  sickness,  and  character,  during  last  voyage, 

Vessel  engaged  in trade,  and  plies  between and  — 

Sanitary  condition  of  vessel, . 

Nature,  sanitary  history,  and  condition  of  cargo, . 

Source  and  wholesomcness  of  water-supply, . 

Source  and  wholesomeness  of  food-supply, . 


Sanitary  history  and  health  of  officers  and  crew, . 

Sanitary  history  and  health  of  passengers,  cabin, . 

Sanitary  history  and  health  of  passengers,  steerage, . 

Sanitary  history  and  condition  of  their  effects, . 

Prevailing  diseases  at  port  and  vicinity, . 

Number  of  cases  and  deaths  from  the  following-named  diseases  during  the  past  two 
weeks  : — 

Diseases.  No.  of  Cases.    No.  of  Deaths. 

Yellow  fever 

Asiatic  cholera 

Cholera  nostras,  or  cholerine 

Small-pox 

Typhus 


Any  conditions  affecting  the  public  health  existing  in  the  port  of  departure,  or 
vicinity,  to  be  here  stated, . 

I  certify  that  .the  vessel  has  complied  with  the  rules  and  regulations  made  under 

the  act  of  February  15, 1893,  and  that  the  vessel  leaves  this  port  bound for , 

United  States  of  America,  via . 

Given  under  my  hand  and  seal  this day  of ,  189 — . 

(Signature  of  consular  officer  :) , 


Par.  3.  Vessels  clearing  from  a  foreign  port  for  any  port  in  the 
United  States,  and  entering  or  calling  at  intermediate  ports,  must  pro- 
cure at  all  said  ports  a  supplemental  bill  of  health  signed  as  provided  in 
Article  1.  If  a  quarantinable  disease  has  appeared  on  board  the  vessel  after 
leaving  the  original  port  of  departure,  or  other  circumstances  presumably 
render  the  vessel  infected,  the  supplemental  bill  of  health  should  be  with- 
held until  stich  sanitary  measures  have  been  taken  as  are  necessary. 

The  following  form  is  prescribed  : —  , 

Par.  4 : 

SUPPLEMENTAL  BILL  OP  HEALTH. 

Port  of . 

Vessel ,  bound  from to ,  U.  S.  A. 

Sanitary  condition  of  port :  . 


State  diseases  prevailing  at  port  and  in  surrounding  country . 

Number  of  cases  and  the  deaths  from  the  following-named  diseases  during  the  past 
two  weeks  : — 


FOREIGN   QUARANTINE. 


445 


Diseases. 

No. 
Cases. 

No. 
Deaths. 

Remarks. 
(Any  condition  affecting  the  public  health  existing 
port,  to  be  stated  here.  ) 

in  the 

Yellow  fever  

Asiatic  cholera 

Small-pox  

Typhus.... 

Number  and  Sanitary  Condition  of  Passengers  Taken  on  at  this  Port,  and  Sanitary  Condition 

of  Effects. 
Cabin,  No. .    Sanitary  condition  and  history . 


Steerage,  No. 


Sanitary  condition  and  history 


(Cancel  Form  A,  B,  or  C,  as  the  case  requires.) 
Form. 

A. — To  the  best  of  my  knowledge  and  belief — 

(Form  A  will  be  used  at  intermediate  ports 
where  the  vessel  does  not  enter  or  clear.) 
B. — I  have  satisfied  myself  that — 

(Form  B  will  be  used  at  intermediate  ports 
where  the  vessel  enters  and  clears.) 


no  quarantinable  disease  has  appeared 
aboard  since  leaving . 


C. — Since  leaving  - 


the  following  quarantinable  disease  has  appeared  on  board  • 


and  I  certify  that  the  necessary  sanitary  measures  have  been  taken. 

I  certify  also  that  with  reference  to  the  passengers,  effects,  and  cargo,  taken  on  at 
this  port,  the  vessel  has  complied  with  the  rules  and  regulations  made  under  the  act  of 
February  15,  1893. 

Given  under  my  hand  and  seal  this day  of ,  189 — . 


(Signature  of  consular  officer  :) 


ARTICLE  II. — INSPECTION. 

Par.  1.  The  officer  issuing  the  bill  of  health  will  satisfy  himself,  by 
inspection  if  necessary,  that  the  conditions  certified  to  therein  are  true. 

Par.  2.  Inspection  is  required  of — 

(a)  All  vessels  from  ports  at  which  cholera  prevails,  or  at  which 
yellow  fever,  small-pox,  or  typhus  fever  prevails  in  epidemic  form. 

(6)  All  vessels  carrying  steerage  passengers. 

But  the  inspection  of  this  class  may  be  limited  to  said  passengers 
and  their  living-apartments,  if  from  a  healthy  port. 

Par.  3.  Inspection  of  the  vessel  is  such  an  examination  of  the  vessel, 
cargo,  passengers,  crew,  personal  effects  of  same,  and  including  exam- 
ination of  manifests  and  other  papers,  food-  and  water-  supply,  as  will 
enable  him  to  determine  if  these  regulations  have  been  complied  with. 

Par.  4.  When  an  inspection  is  required,  it  should  be  made  by  day- 
light, as  late  as  practicable  before  sailing.  The  vessel  should  be  in- 
spected before  the  passengers  go  aboard ;  the  passengers  just  before 
embarkation,  and  the  crew  on  deck  ;  and  no  cargo  or  person  should  be 
allowed  to  come  aboard  after  such  inspection  except  by  permission  of 
the  officer  issuing  the  bill  of  health. 


446  TEXT-BOOK   OF   HYGIENE. 

ARTICLE   III. REQUIREMENTS   WITH   REGARD   TO   VESSELS. 

Par.  1.  Vessels,  prior  to  stowing  cargo  or  receiving  passengers,  shall 
be  mechanically  clean  in  all  parts,  especially  the  hold,  forecastle,  and 
steerage ;  the  bilges  and  limbers  free  from  odor  and  deposit.  The  air- 
streaks  should  be  sufficient  in  number  and  open  for  ventilation.  Disin- 
fection of  the  vessel  may  be  required  by  the  medical  officer  of  the  United 
States. 

Par.  2.  If  any  infectious  disease  has  occurred  during  the  last  voyage, 
the  portions  of  the  vessel  liable  to  have  been  infected  should  be  disin- 
fected. When  required,  this  should  be  done  by  one  of  the  methods 
hereinafter  described. 

Par.  3.  The  air-space  and  ventilation  must  conform  to  the  provisions 
of  the  act  of  Congress  approved  August  2,  1882,  entitled,  "  An  act  to 
regulate  the  carriage  of  passengers  by  sea."1 

Par.  4.  The  food-  and  water-  supply  should  be  sufficient,  and  water 
for  drinking  purposes,  free  from  possibility  of  pollution,  should  be  easily 
accessible. 

Par.  5.  Vessels  departing  from  a  port  where  cholera  prevails  should 
have  two  medical  officers,  if  more  than  250  steerage  passengers  are 
carried. 

Par.  6.  All  bedding  provided  for  steerage  passengers  must  be  de- 
stroyed or  disinfected  before  being  again  used  or  landed,  and  mattresses 
and  pillows  used  by  steerage  passengers  shall  not  be  landed. 

Par.  7.  The  hospitals  of  vessels  carrying  steerage  passengers  should 
be  located  on  the  upper  or  second  deck,  and  not  in  direct  communication 
with  any  steerage  compartment. 

Par.  8.  Excepting  when  absolutely  required,  no  solid  partitions 
should  be  placed  in  any  steerage  compartment,  obstructing  light  and  air. 

ARTICLE   IV. CARGO. 

Par.  1.  At  ports  infected  with  cholera,  earth,  sand,  loam,  soft  or 
porous  rock  should  not  be  taken  as  ballast.  Nor,  at  ports  infected  with 
yellow  fever,  should  such  ballast  be  allowed  on  board  vessels  clearing  for 
ports  south  of  the  southern  boundary  of  Maryland,  when  better  material, 
such  as  hard  rock,  is  obtainable,  or  when  it  is  possible  to  use  water 
ballast. 

Par.  2.  Certain  food-products,  namely,  unsalted  meats,  sausages, 
dressed  poultry,  dried  and  smoked  meats,  rennets,  fresh  butter,  fresh 
milk  (unsterilized),  fresh  cheese,  fresh  bread,  fresh  vegetables,  coming 

1  Computation  of  air-spaee  in  any  steerage  compartment  must  not  include  the  space 
taken  up  by  bunks,  mattresses,  life-preservers,  or  personal  effects. 


FOREIGN    QUARANTINE.  447 

from  cholera-infected  localities,  or  through  such  localities,  if  exposed  to 
infection  therein,  should  not  be  shipped. 

Par.  3.  Fresh  fruits  from  districts  where  cholera  prevails  shall  be 
shipped  only  under  such  sanitary  supervision  as  will  enable  the  inspector 
to  certify  that  they  have  not  been  exposed  to  infection. 

Par.  4.  Articles  of  merchandise,  personal  effects,  and  bedding, 
coining  from  a  district  known  to  be  infected,  or  as  to  the  origin  of  which 
no  positive  evidence  can  be  obtained,  and  which  the  consular  or  medical 
officer  has  reason  to  believe  are  infected,  should  be  subjected  to  disinfec- 
tion prior  to  shipment  by  processes  prescribed  for  articles  according  to 
their  class. 

Par.  5.  New  merchandise  in  general  may  be  accepted  for  shipment 
without  question ;  and  articles  of  new  merchandise,  textile  fabrics,  and 
the  like,  which  have  been  packed  or  prepared  for  shipment  in  an  infected 
port  or  place,  with  a  special  view  to  protect  the  same  from  moisture  inci- 
dent to  the  voyage,  may  be  accepted  and  exempted  from  disinfection. 

Par.  6.  All  rags  and  all  textile  fabrics  used  in  the  manufacture  of 
paper,  collected  or  packed  in  any  foreign  port  or  place,  must,  prior  to 
shipment  to  the  United  States,-  be  subjected  to  disinfection  by  one  of  the 
prescribed  methods : — 

(Old  jute  bags,  old  cotton  bags,  old  rope,  new  cotton  and  linen 
cuttings  from  factories  not  included.) 

Par.  7.  Rags,  old  jute,  old  gunny,  old  rope,  and  similar  articles, 
gathered  or  packed  or  handled  in  any  port  or  place  where  cholera  or 
yellow  fever  prevails,  or  small-pox  or  typhus  fever  prevails  in  epidemic 
form,  should  not  be  shipped  until  the  officer  issuing  the  bill  of  health 
shall  be  satisfied  that  the  port  or  place  has  been  for  thirty  days  free 
from  such  infection,  and  after  the  disinfection  of  the  articles. 

Par.  8.  New  feathers  for  bedding ;  human  and  other  hair,  unmanu- 
factured;  bristles;  wool;  hides  not  chemically  cured,  coining  from  a 
district  where  cholera  prevails,  shatt  be  refused  shipment  until  thirty 
days  have  elapsed  since  last  exposure,  unless  unpacked  and  disinfected 
as  hereinafter  provided. 

Feathers  which  have  been  used  should  be  disinfected,  and  invariably 
by  steam. 

Par.  9.  The  articles  enumerated  in  the  preceding  paragraph  coming 
from  a  district  where  yellow  fever  prevails,  destined  for  ports  or  places 
south  of  the  southern  boundary  of  Maryland  during  the  quarantine 
season,  or  where  small-pox  or  typhus  fever  prevails  in  epidemic  form, 
should  be  refused  shipment,  unless  disinfected  as  hereinafter  provided. 

Par.  10.  Articles  sucli  as  gelatin,  glue,  glue-stock,  fish-glue,  fish- 
bladders,  fish-skins,  sausage-casings,  bladders,  dried  blood,  having  been 


448  TEXT-BOOK   OF   HYGIENE. 

in  any  way  liable  to  infection  in  the  process  of  preparation,  gathering,  or 
shipment,  should  be  disinfected. 

Par.  11.  Any  covering  shipped  from  or  through  an  infected  port 
or  place,  and  which  the  consul  or  medical  officer  has  reason  to  believe 
infected,  should  be  disinfected. 

Par.  12.  Any  article  presumably  infected,  which  cannot  be  disin- 
fected, should  not  be  shipped.1 

ARTICLE    V. — PASSENGERS   AND  CREW. 

Par.  1.  Passengers,  for  the  purposes  of  these  regulations,  are  di- 
vided into  two  classes, — cabin  and  steerage. 

Par.  2.  No  person  suffering  from  a  quarantinable  disease,  or  scarlet 
fever,  measles,  or  diphtheria,  should  be  allowed  to  ship. 

Par.  3.  Steerage  passengers  and  crew,  coming  from  districts  where 
small-pox  prevails  in  epidemic  form,  or  who  have  been  exposed  to  small- 
pox, shall  be  vaccinated  before  embarkation,  unless  they  show  evidence 
of  immunity  to  small-pox  by  previous  attack  or  recent  successful  vaccina- 
tion. 

Par.  4.  Steerage  passengers  and  crew  who,  in  the  opinion  of  the 
inspecting  officers,  have  been  exposed  to  the  infection  of  typhus  fever, 
should  not  be  allowed  to  embark  for  a  period  of  at  least  fourteen  days 
after  such  exposure  and  the  disinfection  of  their  baggage. 

Par.  5.  When  practicable,  passengers  should  not  ship  from  an 
infected  port.  Steerage  passengers  coming  from  cholera-infected  dis- 
tricts must  be  detained  five  days  in  suitable  houses  or  barracks  located 
where  there  is  no  danger  from  infection,  and  all  baggage  disinfected  as 
hereinafter  provided ;  the  said  period  of  five  days  to  begin  only  after 
the  bathing  of  the  passengers,  disinfection  of  all  their  baggage  and 
apparel,  removal  of  all  food  brought  with  them,  and  isolation  from  others 
not  so  treated. 

Par.  6.  Steerage  passengers  from  districts  not  infected  with  cholera, 
shipping  at  a  port  infected  with  cholera,  unless  passed  through  without 
danger  of  infection  and  no  communication  allowed  between  passengers 
and  the  infected  locality,  should  be  treated  as  those  in  the  last  paragraph. 

Par.  7.  Prior  to  sailing  from  ports  infected  with  cholera,  each  pas- 
senger of  the  cabin  class  should  produce  satisfactory  evidence  as  to  his 
exact  place  of  abode  during  the  five  da3's  immediately  preceding  embark- 
ation ;  and  if  it  appear  that  he  or  his  baggage  has  been  exposed  to  con- 
tagion, such  passenger  should  be  detained  such  length  of  time  as  shall 
be  deemed  necessary  by  the  inspecting  officer,  and  the  baggage  should 
be  disinfected. 

1  Upholstered  furniture,  sheep-skins  used  as  wearing-apparel,  bedding,  bones,  horns,  and  hoofs. 


FOREIGN   QUARANTINE.  449 

Par.  8.  The  rules  prescribed  for  the  disinfection  of  the  baggage 
and  personal  effects  of  passengers  and  crew  coming  from  cholera-infected 
ports  should  also  be  observed  with  regard  to  passengers  and  crew  coming 
from  ports  and  places  where  plague,  yellow  fever,  typhus  fever,  or  small- 
pox is  prevailing  in  an  epidemic  form. 

Par.  9.  Should  cholera  break  out  in  the  barracks  or  houses  in 
which  the  passengers  are  undergoing  the  five  days'  observation,  no  pas- 
senger from  said  house  or  barracks  should  embark  until  five  days' 
isolation  from  the  last  case  and  a  repetition  of  the  sanitary  measures 
previously  taken. 

Par.  10.  All  baggage  of  steerage  passengers  destined  for  the  United 
States  shall  be  labeled.  If  the  bagguge  has  been  inspected  and  passed, 
the  label  shall  be  a  red  label  bearing  the  name  of  the  port,  the  steam-ship 
on  which  the  baggage  is  to  be  carried,  the  word  "  inspected"  in  large 
type,  the  date  of  inspection,  and  the  seal  or  stamp  of  the  consular  or 
medical  officer  of  the  United  States.  All  baggage  that  has  been  disin- 
fected shall  bear  a  yellow  label,  upon  which  shall  be  printed  the  name  of 
the  port,  the  steam-ship  upon  which  the  baggage  is  to  be  carried,  the 
word  "  disinfected"  in  large  type,  the  date  of  disinfection,  and  the  seal 
or  stamp  of  the  consular  or  medical  officer  of  the  United  States.  It  is 
understood,  and  it  will  be  so  printed  on  the  blank,  that  the  label  is  not 
valid  unless  bearing  the  consular  or  medical  officer's  stamp  or  seal. 

Par.  11.  Each  steerage  passenger  should  be  furnished  with  an 
inspection  card.  This  card,  stamped  by  the  consular  or  medical  officer, 
is  to  be  issued  to  every  member  of  a  family  as  well  as  to  the  head 
thereof. 

Par.  12.  Form  of  inspection  card  (see  next  page). 

Par.  13.  Cabin  passengers  from  cholera-infected  ports  or  places 
should  be  given  a  special  inspection  card,  on  which  shall  be  printed  the 
port  of  departure,  name  of  passenger,  name  of  ship,  date  of  departure, 
and  an  indicated  space  for  the  seal  or  stamp  of  the  consular  or  medical 
officer. 

Par.  14.  The  baggage  of  such  cabin  passengers  shall  be  labeled  in 
the  same  manner  as  steerage  baggage. 

Par.  15.  In  a  port  where  cholera  prevails,  or  where  yellow  fever 
prevails  in  epidemic  form,  the  crews  of  passenger-ships  should  remain 
on  board  during  their  stay.  Should  additional  men  be  shipped,  the 
same  precautions  should  be  observed  with  them  as  in  the  case  of 
steerage  passengers.  If  it  is  considered  necessary,  the  crews  of  freight- 
ships  may  be  similarly  treated,  at  the  discretion  of  the  medical  officer. 

Par.  16.  Passengers  and  crews,  merchandise  and  baggage,  prior  to 
shipment  at  u  non-infected  port,  but  coming  from  an  infected  locality, 


450 


TEXT-BOOK   OF   HYGIENE. 


(Immigrants  and  Steerage  Passengers.) 

Port  of  Departure Date  of  Departure, 

Name  of  Ship 

Name  of  Immigrant Last  Permanent  Residence 


Inspected  and  passed  at 

Passed  at  quarantine,  port  of 

Passed  by  Immigration  Bu- 

., U.  S. 

reau,  port  of  . 

C        Seal  or  Stamp        } 
<  of  Consular  or  Med-  > 

(          ical  Officer.           ) 

(Date.) 

(Date.) 

(The  following  to  be  filled  in  by  ship's  surgeon  or  agent  prior  to  or  after  embarkation.) 


J 

•     *                     J 

Berth  No. 

i  i 

>,                                                      *     3 
•9             •                                         i  2  1  S  t 

jj                                                                                                                                                      £      t>     .cj      t*>    ^ 
(M                   ^<lO<Ct-00                   0^(M03^K                       §"§ 

1 

w  & 

rt(NW-J<                                                 ^rt^S^S                   .P.             • 

- 

(REVERSE  SIDE.) 

Keep  this  Card  to  avoid  detention  at  Quarantine  and  on  Railroads 
in  the  United  States. 


Diese  Karte  muss  aufbewahrt  werden,  um  Aufenthalt  an  der  Quar- 
antane,  sowie  auf  den  Eisenbalmen  der  Vereinigten  Staaten  zu  vermeiden. 


Cette  carte  doit  6tre  conservee  pour  eviter  une  de"tention  a  la  Quar- 
antaine,  ainsi  que  sur  les  chemins  de  fer  des  fitats-Unis. 


Deze  kaart  moet  bewaard  worden,  ten  einde  oponthoud  aan  de  Quar- 
antijn,  alsook  op  de  ijzeren  wegen  der  Vereenigile  Staten  te  vennijden. 


Conservate  qnesto  biglietto  onde  evitare  dctenzione  alia  Quarantiiia 
e  sulle  Ferrovie  degli  Stati  Uniti. 


Tento   Hstek   musite    uscliovati,  nechoete-li   ukaranteny    (zastavenf 
ohledn6  zji^tfini  zdravi)  neb  na  draze  ve  spojenych  stateuh  zdrzenl  byti. 


Tuto  kartodku  treba  trlmat'  u  sebe  aby  sa  predeslo  zderzovanu  v 
karantene  aj  na  zeleznici  ve  Spojenych  Statoch. 


FOREIGN   QUARANTINE.  451 

should  be  subject  to  the  same  restrictions  as  are  imposed  in  an  infected 
port. 

ARTICLE   VI. — REQUIREMENTS  AT   SEA. 

Par.  1.  The  master  of  the  vessel  should  cause  the  following  rules 
(which  comprise  those  recommended  by  the  International  Conference  at 
Rome,  1885)  to  be  observed  during  the  voyage  : — 

(a)  The  soiled  body-linen  of  passengers  and  crew  suffering  from 
infectious  disease  should  be  at  once  immersed  in  boiling  water  or  in  a 
disinfecting  solution. 

(6)  The  water-closets  should  be  washed  and  disinfected  twice  a  day. 

(c)  Rigorous  cleanliness  and  free  ventilation  should  be  maintained 
during  the  voyage  on  board  all  ships. 

Par.  2.  An  inspection  of  the  vessel,  including  the  steerage,  should 
be  made  by  the  ship's  physician  once  each  day. 

Par.  3.  Should  cholera  (or  cholerine),  yellow  fever,  typhus  fever, 
or  small-pox  appear  on  board  a  ship  while  at  sea,  those  who  first  show 
symptoms  of  these  diseases  will  be  immediately  sent  to  the  hospital ;  the 
ship's  physician  will  then  immediately  notify  the  captain,  and  all  of  the 
effects  liable  to  convey  infection  which  have  been  in  use  will  be  destroyed 
or  disinfected. 

Par.  4.  The  compartments  occupied  by  those  who  fall  sick  with 
infectious  disease  should  be  disinfected,  and,  as  far  as  possible,  the  com- 
partments thus  disinfected  should  be  freely  exposed  to  the  air.  If  the 
vessel  is  an  iron  steamer  and  the  compartments  suitable,  the  entire  com- 
partment should  be  disinfected  by  steam.  The  articles  liable  to  convey 
infection  should  remain  in  the  compartments  during  the  disinfection. 
After  disinfection  of  the  compartments  the  bedding  and  clothing  may  be 
removed  and  dried. 

Par.  5.  Patients  with  infectious  disease  should  be  isolated. 

Par.  6.  The  hospital  should  be  disinfected  as  soon  as  it  becomes 
vacant. 

Par.  7.  The  dead  should  be  enveloped  in  a  sheet  saturated  with 
one  of  the  strong  disinfecting  solutions,  without  previous  washing  of  the 
body,  and  at  once  placed  in  a  coffin  hermetically  sealed,  or  buried  at  sea. 

Par.  8.  A  clinical  record  should  be  kept  on  the  prescribed  form,  by 
the  ship's  surgeon,  of  all  cases  of  sickness  on  board,  and  delivered  to 
the  quarantine  officer  at  the  port  of  arrival. 

Par.  9.  Under  the  foregoing  paragraphs,  disinfecting  solutions  are 
limited  to  the  following :  Strong :  acid  solution  of  bichloride  of  mer- 
cury (1  to  500) ;  a  1  to  20  solution  of  pure  carbolic  acid.  Weak  :  acid 
solution  of  bichloride  of  mercury  (1  to  1000) ;  pure  carbolic  acid, 
1  to  40. 


452  TEXT-BOOK    OF   HYGIENE. 

Par.  10.  Form  for  clinical  report1 : — 


Name. 

Age. 

Sex. 

Last  per- 
manent 
residence 

Date  of 
admission. 

Disease. 

Dis- 
charged. 

Result. 

Clinical  history. 

1 

Clinical  history. 

Clinical  history. 

Clinical  history. 

Paf.  11.  Sailing-vessels  leaving  ports  infected  with  yellow  fever, 
and  destined  for  any  port  in  the  United  Slates  south  of  the  southern 
boundary  of  Maryland,  which  is  not  provided  with  proper  facilities  for 
treatment,  shall,  during  the  quarantine  period,  be  directed  by  the  con- 
sular or  medical  officer  to  proceed,  for  disinfection  and  treatment,  to  some 
quarantine  station  in  the  United  States  provided  with  the  required 
facilities. 

ARTICLE  VII. — DISINFECTION. 

Par.  1.  The  disinfection  of  iron  vessels  shall  be  as  follows  : — 

(a)  Holds. — After  mechanical  cleansing,  the  hold  to  be  thoroughly 
washed  with  an  acid  solution  of  bichloride  of  mercury  1  to  800  (mercury 
1  part,  hydrochloric  acid  2  parts,  water  800  parts),  applied  under  press- 
ure to  all  surfaces  by  means  of  a  hose. 

In  case  the  Disinfection  is  Required  for  Yellow  Fever. 

If  the  cargo  is  so  stowed  as  to  admit  of  disinfection,  the  hold  and 
cargo  may  be  disinfected  without  breaking  bulk,  by  sulphur  dioxide,  10 
per  cent,  per  volume  strength,  forty -eight  hours'  exposure  for  iron  and 
seventy-two  hours  for  wooden  vessels. 

(b)  Steerage  and  Forecastle. — The  same  treatment  should  be  given 
the  steerage  and  forecastle  as  the  hold,  but  when  practicable  steam  disin- 

1  Temperature  to  be  recorded. 


FOREIGN    QUARANTINE.  453 

fection  of  these  compartments  should  be  practiced.  The  temperature  in 
all  parts  of  the  compartments  is  to  be  not  less  than  100°  C. 

(c)  Cabins,  Officers1  Quarters,  Staterooms,  etc. — The  bedding, 
fabrics,  and  carpets  should  be  removed  and  disinfected  by  steam.  After 
thorough  mechanical  cleansing,  the  exposed  surfaces  of  fabrics  which 
cannot  be  removed  should  be  washed  with  a  solution  of  bichloride  of 
mercury1  1  to  1000,  or  3-per-cent.  solution  of  carbolic  acid,  both  of  which 
should  be  removed,  but  not  under  two  hours.  Afterward  the  apartments 
should  be  thoroughly  dried  and  aired. 

Par.  2.  The  disinfection  of  wooden  vessels  is  to  be  accomplished 
as  follows  :  After  mechanical  cleansing,  washing  out  the  bilges  until 
clean,  etc.  (first),  by  fumigation  l>y  sulphur  dioxide,  10-per-cent.  strength, 
twenty-four  hours  in  the  cabin  and  forecastle  and  forty-eight  hours  in  the 
hold ;  and  (second)  flushing  or  washing  with  acid  solution  of  bichloride 
of  mercury  in  large  quantity  (1  to  800).  The  bilges  to  be  first  flushed 
with  sea-water,  pumped  out,  and  then  treated  with  the  acid  solution  of 
bichloride  of  mercury  in  large  quantity,  allowed  to  remain  in  long  con- 
tact. In  addition  to  the  sulphur  fumigation  of  such  apartments,  the 
cabins,  forecastle,  and  other  apartments,  and  their  contents,  to  be  treated 
as  those  on  iron  vessels. 

Cargo. 

Par.  3.  Disinfection  of  rags  and  old  jute,  etc.,  shall  be  by  one  of  the 
following  methods : — 

(a)  By  boiling  in  water  for  not  less  than  thirty  minutes. 

(6)  By  steam  at  the  temperature  of  100°  C.  for  not  less  than  thirty 
minutes  after  such  temperature  is  reached. 

(c)  By  exposure  for  not  less  than  six  hours  in  a  closed  compartment 
to  a  4-per-cent.  strength  (per  volume)  of  sulphur-dioxide  gas, — made  by 
burning  roll  sulphur  or  by  the  liberation  of  liquefied  sulphur  dioxide, — 
allowance  to  be  made  for  leakage  by  increasing  the  amount  of  sulphur. 

Par.  4.  In  all  of  the  above  methods,  the  rags,  old  jute,  etc.,  must  be 
unbaled,  and  in  the  disinfection  by  steam  or  sulphur  the  rags  must  be 
loosely  spread  on  racks  (preferably  wire  netting)  in  layers  of  not  more 
than  six  inches  in  depth,  and  in  such  a  manner  as  to  insure  the  diffusion 
of  the  gas  to  all  parts  alike. 

The  articles  must  not  at  any  time  occupy  more  than  50  per  cent,  of 
the  total  cubic  space,  and  the  exposure  to  date  from  the  complete  com- 
bustion of  the  sulphur. 

Par.  5.  New  feathers  for  bedding  shall  be  disinfected  by  one  of  the 
following  methods : — 

'  Polished  metal  is  injured  by  mercury,  and  leather  by  steam. 


454  TEXT-BOOK   OF   HYGIENE. 

(a)  By  steam  at  a  temperature  of  100°  C.  for  a  period  of  thirty 
minutes  after  such  temperature  has  been  reached. 

(6)  B}r  exposure  to  sulphur  dioxide,  4-per-cent.  strength  per  volume, 
for  not  less  than  six  hours. 

Par.  6.  Human  hair  or  other  hair,  unmanufactured,  and  bristles,  to 
be  disinfected  by  sulphur  dioxide,  4-per-cent.  strength  per  volume,  six 
hours,  or,  if  not  clean,  by  a  solution  of  pure  carbolic  acid,  4-per-cent. 
strength,  the  articles  to  be  thoroughly  saturated. 

Par.  7.  Wool  to  be  disinfected  by  sulphur  dioxide,  4-per-cent. 
strength  per  volume,  for  not  less  tban  twenty  hours,  the  wool  to  be  tin- 
baled  and  loosely  spread  on  racks,  as  in  the  manner  provided  for  the 
disinfection  of  rags. 

Par.  8.  Hides  to  be  disinfected  by  '"sulphur  dioxide,  4-per-cent. 
strength  per  volume,  for  not  less  than  twenty  hours,  or  by  thorough 
saturation  with  a  solution  of  pure  carbolic  acid,  4-per-cent.  strength ; 
hides  to  be  invariably  unbaled  for  the  purpose. 

Par.  9.  Articles  mentioned  in  paragraph  10,  Article  IV,  should  be 
disinfected  by  being  spread  on  racks  and  exposed  to  sulphur  dioxide, 
4  per  cent,  per  volume,  twenty  hours.  , 

Par.  10.  Coverings  should  be  disinfected — 

(a)  In  the  hold,  by  exposure  to  sulphur  dioxide,  10-per-cent. 
strength  per  volume,  for  twelve  hours ;  the  cargo  being  so  stowed  as  to 
allow  access  to  all  parts  of  such  surfaces. 

(6)  By  breaking  bulk  and  exposure  to  sulphur  dioxide,  4-per-cent. 
strength  per  volume,  for  twenty-four  hours. 

(c)  By  wetting  thoroughly  with  solution  of  bichloride  of  mercury 
1  to  800. 

Par.  11.  The  disinfection  of  personal  effects,  prescribed  by  these 
regulations,  should  be  as  follows  : — 

(a)  Clothing  and  bedding  should  be  disinfected  by  (1)  exposure 
to  steam  from  100°  to  102°  C.  for  thirty  minutes  after  such  temperature 
is  reached,  or  by  boiling  for  thirty  minutes  ;  (2)  immersion  in  bichloride 
solution  1  to  800,  or  solution  of  pure  carbolic  acid,  3  per  cent.,  until 
thoroughly  wetted,  and  allowed  to  dry  before  washing. 

This  last  process  (2)  to  be  used  only  for  articles  that  will  be  injured 
by  steam  or  boiling.1 

(6)  Cooking  and  eating  utensils  should  be  immersed  in  boiling 
water. 

NOTE. — A  4  per  cent,  per  volume  strength  of  sulphur  dioxide  can  be  obtained  by 
burning  not  less  than  4  pounds  2  ounces  of  sulphur  to  each  1000  cubic  feet  of  space ;  the 
compartment  to  be  air-tight. 

1  Articles  of  rubber,  leather,  celluloid,  gutta-percha,  hats,  furs,  skins,  and  similar  arti- 
cles, are  injured  by  steam  or  boiling. 


FOREIGN    QUARANTINE.  455 

A  10  per  cent,  per  volume  strength  can  only  be  obtained  by  one  of 
the  following  methods  :  By  the  use  of  a  special  furnace,  or  by  liquefied 
sulphur-dioxide  gas. 

ARTICLE   VIII. — RECORDS,   REPORTS,   ETC. 

The  officer  making  the  inspection  will  preserve  in  his  office  a  record 
of  each  inspection  made.  A  copy  of  said  record  will  be  forwarded  weekly 
to  the  Supervising  Surgeon-General  of  the  Marine-Hospital  Service,  at 
Washington,  D.  C. 

In  addition  to  the  duties  already  prescribed,  the  medical  officer, 
when  detailed  in  accordance  with  the  Act  of  Congress  approved  Febru- 
ary 15,  1893,  shall  furnish  such  reports  to  the  Supervising  Surgeon- 
General  of  the  Marine-Hospital  Service  as  may  be  required  by  the  latter. 

NOTES  FOR  THE  INFORMATION  OF  MASTERS  OF  VESSELS  AND  OTHERS. 

FORMULAE   FOB   STRONG    DISINFECTING    SOLUTIONS. 

Bichloride  of  Mercury.     (1 : 500. ) 

Bichloride  of  mercury 1  part. 

Hydrochloric  acid 2  parts. 

Water 500  parts. 

Mix. 

Carbolic  Acid. 

Carbolic  acid  (pure) 50  parts. 

Warm  water 1000  parts. 

FORMULA  FOR  WEAK  SOLUTIONS. 
Bichloride  of  Mercury.     (1 : 1000. ) 

Bichloride  of  mercury 1  part. 

Hydrochloric  acid 2  parts. 

Water 1000  parts. 

Carbolic  Acid. 

Carbolic  acid  (pure) 25  parts. 

Warm  water 1000  parts. 

DISINFECTION  OF  HOSPITALS,  INFECTED  COMPARMENTS,  ETC. 

(a)  By  steam  as  provided  in  Article  VII,  paragraph  (c);  or,  when 
steam  is  not  available — 

(6)  By  methods  prescribed  in  Article  VII,  paragraphs  (a)  and  (c). 

Water-closets,  etc.,  should  be  disinfected  by  strong  solution  of 
bichloride  of  mercury  or  carbolic  acid.1 

It  is  suggested  that  a  vessel  should  carry,  for  every  100  passen- 
gers:  Bichloride  of  mercury,  5  pounds;  hydrochloric  acid,  10  pounds; 
carbolic  acid,  10  pounds. 

1  The  use  of  these  disinfecting  solutions  does  not  preclude  the  additional  use  of  hypo- 
chlorite  of  lime. 


456  TEXT-BOOK   OF   HYGIENE. 

EFFICIENCY   OF   FOREIGN    REGULATIONS. 

The  wisdom  of  this  method  of  procedure  and  the  efficient 
working  of  these  regulations  are  demonstrated  by  the  following 
statement  taken  from  the  report  of  the  medical  officer  of  the 
Marine-Hospital  Service  on  duty  at  Naples,  Italy,  where,  during 
the  summer  of  1893,  cholera  was  epidemic : — 

"  From  the  15th  of  July  to  August  17th  there  were  eight 
vessels  cleared  from  Naples  with  steerage  passengers, — four  for 
New  York  and  four  for  South  American  ports.  The  first  to 
leave  was  the  Karamania,  for  New  York,  on  July  15th.  No 
cholera  at  that  time  existed  in  Naples.  The  first  case  occurred 
in  Naples  on  the  night  of  the  16th,  and  the  result  of  the  bac- 
teriological examination  was  not  known  until  the  afternoon  of 
the  17th  or  morning  of  the  18th. 

"  The  passengers  for  the  Karamania  and  the  ship  itself 
were  put  through  the  established  routine.  The  ship  was 
cleaned;  ventilation,  etc.,  altered  to  conform  with  the  United 
States  law ;  closets  and  hospitals  put  in  good  order ;  water-  and 
food-  supply  attended  to ;  passengers  inspected  and  vaccinated, 
and  both  their  baggage  and  clothing  searched  for  food.  Three 
days  after  sailing,  i.e.,  on  the  18th,  a  death  from  cholera 
occurred,  and  just  before  reaching  New  York  there  were  two 
more.  It  is  not  unlikely  that  the  infection  in  the  first  cases  was 
traceable  to  the  same  source  as  those  occurring  in  Naples  on 
the  16th.  It  is  more  than  probable  that  but  for  the  careful 
exclusion  of  food  brought  by  passengers  there  would  have  been 
more  cases  on  the  remaining  three  ships  for  the  United  States. 
The  regulations  governing  infected  ports  were  rigidly  enforced. 
The  first  vessel  to  leave,  four  days  after  the  cholera  was  an- 
nounced, was  the  Massilia.  Her  passengers  were  met  at  the 
trains  and  conducted  immediately  on  board  ;  were  there  isolated 
three  days,  and  all  their  baggage  transferred  across  city  unopened. 
All  food  was  carefully  looked  into  ;  all  from  persons  or  baggage 
excluded ;  and  the  baggage  of  a  few,  about  whose  antecedents 
there  was  doubt,  disinfected  by  steam.  The  ship  was  warped 


FOREIGN    QUARANTINE.  457 

out  some  distance  from  the  pier  every  night,  and  an  inspector 
kept  on  board  night  and  day.  There  being  no  cholera  known 
to  exist  anywhere  in  Italy  outside  of  Naples,  it  was  not  thought 
necessary  to  disinfect  all  baggage  or  isolate  five  days.  She 
arrived  safely  in  New  York  without  mishap.  The  remaining 
two  for  the  United  States  were  the  Wcser  and  Caslimire ;  in 
both  cases  the  regulations  were  enforced  in  detail.  One  lay 
about  a  mile  and  a  half  off  shore  during  her  five  days.  The 
other  cruised  at  sea.  In  both  cases  an  inspector  was  kept 
aboard  day  and  night.  Both  escaped  cholera. 

"  The  four  for  South  America,  with  the  result  in  each  case, 
were  as  follow :  The  figures  are  not  official,  but  are  practically 
accurate  in  every  respect.  All  were  turned  back  by  the  South 
American  authorities:  Vencinzio  Florio, — about  50  deaths; 
Andrea  Dorio, — 90  on  way  out,  total  not  ascertained ;  El 
Remo, — 84  deaths ;  Carlo  R., — -about  230  deaths. 

"  To  summarize,. then,  eight  ships  left  Naples.  The  water- 
supply  was  the  same  and  the  food  about  the  same ;  the  class  of 
passengers  identical,  and  their  places  of  origin  similar, — in 
many  cases  identical.  All  four  leaving  without  precautions 
became  floating  pest-houses.  Of  the  four  for  the  United  States, 
the  one  leaving  before  cholera  appeared  in  Naples  had  3  deaths ; 
the  other  three  were  made  to  conform  to  the  regulations,  and 
all  escaped.  In  other  words,  every  ship  that  left  Naples  had 
cholera  except  those  in  whose  case  the  '  infected  port '  regula- 
tions were  carried  out ;  and  of  the  five  that  had  cholera,  the 
only  one  that  escaped  with  less  than  50  deaths  was  the  one  on 
which  our  '  non-infected  port '  regulations  were  enforced,  she 
having  only  3  deaths  en  route.  In  addition,  the  enforcement 
of  the  regulations  compelled  the  abandonment  of  a  number  of 
other  sailings  for  the  United  States.  The  escape  of  the  Massilia, 
Caslimire,  and  Weser  may  be  '  post,'  not  '  propter  hoc,'  but  we 
certainly  have  the  right  to  consider  the  evidence  to  be  strongly 
on  the  side  of  '  propter.' ' 


458  TEXT-BOOK  OF  HYGIENE. 

DOMESTIC  QUARANTINE. 

The  trans-oceanic  part  of  the  voyage  completed,  the  vessel 
arrives  in  the  waters  of  the  United  States,  and  here  she  is  con- 
fronted by  a  municipal,  State,  or  national  quarantine  station, 
where  the  question  will  be  determined  whether  the  measures 
prescribed  have  been  carried  out,  whether  they  have  been  effect- 
•  ive  in  the  particular  case,  and,  in  fine,  whether  the  vessel,  her 
crew,  passengers,  and  cargo  are  or  are  not  a  menace  to  the 
health  of  the  city  and  the  country  at  large. 

MARITIME    QUARANTINE    STATIONS. 

In  describing  a  maritime  quarantine  station  it  should  be 
borne  in  mind  that  the  details  in  the  plant  must  vary  in  accord- 
ance with  the  special  demands  of  each  port. 

Thus,  it  is  not  to  be  expected  that  at  Charleston,  where 
immigration  is  limited,  there  should  be  the  same  provisions  for 
detention  of  immigrants  as  at  New  York,  through  whose  por- 
tals more  than  one-third  of  a  million  of  immigrants  pass  each 
year ;  or  San  Francisco,  where  enter  the  throng  of  travelers  and 
immigrants  from  the  far  East. 

We  should  not  expect  that  Boston,  in  the  more  salubrious 
North,  would  have  the  means  or  adopt  the  practice  of  discharging 
ballast,  cleaning  and  fumigating  every  vessel  from  an  infected 
port,  which  is  the  invariable  custom  at  Pensacola. 

But,  leaving  these  variations  for  subsequent  notice,  the  first 
thing  to  be  considered,  in  the  establishment  of  a  complete  mari- 
time quarantine,  is  proper  location.  This  must  be  at  a  point 
remote  from  city  or  village  boundaries,  and  not  likely  to  be 
encroached  upon  by  urban  growth.  It  should  be  more  or  less 
removed  from  the  channels  of  commerce,  and  yet  be  easily 
accessible.  Indifference  to  proper  location  could  very  readily 
make  *the  quarantine  station  a  source  of  danger  instead  of  a 
protection. 


DOMESTIC    QUARANTINE.  459 

THE   QUARANTINE   PLANT. 

The  requirements  of  a  maritime  quarantine  station  may  be 
enumerated  as  follows :  1 .  A  boarding-station.  2.  A  boarding- 
vessel.  3.  Anchorages.  4.  Wharves  with  warehouse,  disin- 
fecting machinery,  and  machinery  for  discharge  of  ballast.  5. 
Lazaretto,  or  hospital  for  treatment  of  contagious  diseases.  6. 
Hospital  for  treatment  of  non-contagious  diseases.  7.  Barracks 
for  the  detention,  in  groups,  of  suspects,  or  persons  who  have 
been  exposed  to  contagion  or  infection.  8.  Bath-house.  9. 
Water-supply.  10.  A  cremation  furnace.  11.  Quarters  for 
medical  officers.  12.  Laundry. 

1.  THE   BOARDING-STATION.— This  includes  a  boat-house, 
with  boatmen's  quarters  so  located  as  to  avoid  infection  from 
the  Lazaretto,  and  to   be  within  easy  reach  of  passing  com- 
merce. 

2.  BOARDING- VESSEL. — The  facilities  for  boarding  and  in- 
spection   will  vary  with   the  location  of  the   station,  whether 
within  the  limits  of  a  land-locked  harbor  or  exposed  to  the  full 
force  of  wind  and  sea.    In  the  former  case  a  steam-  or  naphtha- 
launch,  or  even  a  row-boat,  will  suffice ;  but  in  the  latter  case 
the  boarding-boat  must  be  a  steamer,  preferably  of  the  sea-going 
tug-boat  type,  for  it  must  be  remembered  that  any  delay  in 
making  the  inspection  inflicts  hardship  on  commerce,  and  must 
inevitably  produce  discontent  and  complaint. 

3.  ANCHORAGES. — Two  anchorages,  one  for  infected  and 
one  for  non-infected  vessels.     The  anchorage  for  the  detention 
of  the  infected  vessel  should  be  conveniently  removed  from  the 
main  establishment  and  safely  remote  from  the  track  of  com- 
merce.    Its  position   should  be  sheltered,  and  good  holding- 
ground   for  vessels'  anchors  is  of  the  first  importance.     The 
channel  to  the  anchorages,  and,  if  necessary,  their  boundaries, 
should  be  plainly  marked  by  buoys. 

4.  WHARVES. — A  wharf  or  pier  is  a  prime  essential  in  the 
equipment  of  a  complete   station,  and   should   be  located  in 
water  at  least  twenty  feet  deep,  and  should  be  of  such  length 


460  TEXT-BOOK   OF   HYGIENE. 

that  the  largest  vessels  trading  at  the  port  can  lie  there  safely; 
at  least,  in  all  ordinary  weather.  Upon  this  wharf  there  should 
be  a  warehouse  for  the  storage  of  baggage  and  portions  of 
cargo  (practically,  cargo  is  never  fully  discharged,  being  disin- 
fected in  situ}.  On  the  wharf  should  be  placed  the  steam 
disinfecting  chambers,  sulphur-furnaces,  and  tanks  for  holding 
disinfecting  solutions.  (At  certain  stations  the  disinfecting 
apparatus  is  necessarily  placed  on  a  barge.)  When  required, 
a  special,  additional  wharf  should  be  provided  for  the  discharge 
of  ballast. 

Steam  Disinfecting  Chambers. — The  principle  of  disinfec- 
tion by  steam  was  first  advocated  by  Dr.  A.  N.  Bell,  of  Brook- 
lyn ;  but  the  credit  of  first  designing  apparatus  for  the  special 
purpose  belongs  to  Dr.  Joseph  Holt,  and  his  design  was  subse- 
quently improved  upon  by  Dr.  Wilkinson  and  others. 

Steam  Chambers. — These  chambers  consisted  of  cylindrical 
shells,  made  of  strong  boiler-iron,  40  to  50  feet  long  and  7  to  8 
feet  in  diameter  (inside  measurement),  furnished  with  doors  at 
each  end.  The  steam  was  admitted  directly  to  the  interior  of 
the  chamber,  and  in  addition  there  was  a  coil  of  pipe  for  the 
application  of  dry  heat.  These  chambers  were  fairly  efficient 
in  action,  but  there  was  a  great  waste  of  space,  and  with  the 
exercise  of  every  possible  care  there  was  always  more  or  less 
wetting  of  fabrics  by  the  water  of  condensation.  Many  im- 
provements have  been  made  from  time  to  time  in  the  construc- 
tion of  steam  disinfecting  chambers,  those  constructed  for  the 
national  quarantine  station  at  San  Francisco,  Cal.,  being  of  the 
same  general  construction,  but  dispensing  with  the  coil  of  pipe, 
and  substituting  therefor  a  jacket  surrounding  the  entire 
chamber. 

The  most  recent  steam  chambers  are  the  joint  plan  of  Passed 
Assistant  Surgeon  J.  J.  Kinyoun,  Marine-Hospital  Service,  and 
Mr.  W.  H.  Francis,  of  the  Kensington  Engine- Wrorks  of  Phil- 
adelphia. They  are  of  rectangular  section,  16  feet  in  length, 
4  feet  6  inches  in  width,  and  5  feet  6  inches  in  height,  and  are 


DOMESTIC   QUARANTINE.  461 

provided  with  steam-tight  doors  opening  at  either  end.  The 
chambers  are  constructed  of  an  inner  and  outer  steel  shell  2| 
inches  apart,  with  cast-iron  end  frames,  intermediate  truss  bands, 
and  of  stay-bolt  construction. 

The  doors  have  concave  steel  plates  riveted  to  cast  angle 
frames  fitted  with  heavy  rubber  gaskets ;  they  are  handled  by 
convenient  cranes,  and  drawn  tight  by  drop-forged  steel  eye- 
bolts,  swinging  in  and  out  of  slots  in  the  door-frames.  The 
rectangular  form  is  adopted  in  preference  to  the  round,  as  it 
gives  the  most  effective  space  during  exposure,  with  little  loss 
of  steam,  and  enables  cars  on  tracks  to  be  readily  handled  in 
and  out.  The  jacket  is  used  to  give  perfect  circulation  and 
distribution  of  heat,  to  prevent  condensation,  and  to  dry  the 
goods  exposed.  The  jackets,  which  are  filled  with  steam  during 
the  entire  operation  of  the  plant,  make  the  chambers  drying 
ovens ;  so  that  the  articles  to  be  disinfected  are  brought  to  the 
required  temperature  before  the  admission  of  steam  to  the  inner 
chamber,  and  are  thoroughly  dried  after  the  steam  has  been 
exhausted. 

In  the  experiments  of  Professor  Koch  in  connection  with 
Dr.  Wollfhiigel  it  was  found  that  hot  air  alone,  even  at  a  tem- 
perature of  230°  to  248°  F.,  after  an  exposure  of  three  hours, 
would  not  with  certainty  destroy  bacilli  and  spores.  It  is  neces- 
sary, therefore,  to  eliminate  the  possibility  of  the  pocketing  of 
air,  or  of  a  mixture  of  air  and  steam,  during  exposure.  To 
prevent  this  a  vacuum  pump  is  attached  to  the  system  of  piping, 
whereby  a  vacuum  of  15  to  20  inches  is  produced  in  the 
chamber  prior  to  the  admission  of  steam.  In  previous  chambers 
this  important  point  was  neglected,  and  this  accounts  for  the 
unreliable  results  obtained  by  a  number  of  disinfecting  plants. 

For  convenience  of  handling  the  goods  to  be  disinfected, 
each  chamber  is  provided  with  two  cars  of  light  wrought- 
iron  construction,  with  removable  trays  with  bottoms  of  galvan- 
ized-iron  wire  netting,  and  having  a  series  of  bronze  wardrobe- 
hooks  in  the  top  of  the  frame-work,  thus  permitting  the  articles 


462  TEXT-BOOK   OF   HYGIENE. 

to  be  laid  out  upon  the  trays,  or,  in  the  case  of  finer  clothing,  to 
be  hung  upon  the  hooks.  The  doors  at  both  ends  allow  the 
cars  to  be  brought  in  at  one  end  and  removed  at  the  other,  thus 
securing  complete  separation  of  infected  and  disinfected  articles. 
After  exposure  the  cars,  upon  being  unloaded,  are  returned  to 
the  working  end  of  the  chamber  by  means  of  transfer  tables 
and  side-tracks,  permitting  a  continuous  working  of  the  plant. 

The  system  of  piping  is  so  arranged  that  steam  may  be 
admitted  to  the  top  or  bottom  of  the  chamber  at  will,  through 
several  openings,  and  has  perfect  circulation.  Galvanized-iron 
hoods  are  placed  in  the  chambers,  so  that  steam  is  not  forced 
directly  on  the  clothing.  The  chamber  is  provided  with  ther- 
mometers to  register  the  temperature,  vacuum  and  steam  gauges, 
safety-valves,  traps,  and  is  covered  with  magnesia  non-conducting 
covering. 

/S 'ul phur- Furnace. — For  a  long  time  the  method  of  sulphur 
fumigation  pursued  was  to  put  into  iron  pots  a  quantity  of  sul- 
phur varying  from  three  to  four  pounds  to  one  thousand  cubic 
feet,  igniting  this  by  means  of  alcohol,  and  to  place  them  in  the 
hold  or  apartment  to  be  disinfected.  An  apparatus  was  de- 
signed by  Passed  Assistant  Surgeon  J.  J.  Kinyoun,  Marine-Hos- 
pital Service,  for  the  purpose  of  producing  SO2  in  greater  per- 
centage, and  consisted  of  a  furnace  built  on  the  reverberatory 
plan,  with  a  series  of  shelves  arranged  one  above  another,  each 
shelf  carrying  a  pan  of  burning  sulphur.  A  forced  draught  is 
kept  up  by  means  of  a  fan-blower  connected  at  the  bottom. 
The  draught  of  air  charged  from  the  burning  sulphur  is  made 
to  reach  and  pass  over  the  shelf  above  by  means  of  apertures 
made  by  shortening  the  shelves  alternately  at  their  rear  and 
front  extremities.  With  an  experimental  furnace,  Dr.  Kinyoun 
states  that  "repeated  experiments  gave  from  14  to  16  per  cent, 
of  SO2,  temperature  21°  C,  while  burning  sulphur  in  a  closed 
place  gave  only  6  per  cent,  at  21°  C., — i.e.,  the  air  would  not 
support  the  combustion  of  sulphur  above  that  percentage." 

This  has  been  almost  entirely  superseded  by  a  furnace  that 


DOMESTIC   QUARANTINE.  463 

is  simpler  in  construction,  and  which  has  given  admirable  re- 
sults in  practice.  The  furnace  is  douhle,  and  has  been  provided 
with  small  fire-boxes  at  each  end,  over  which  are  placed  two 
shallow  cast-iron  pans  five  feet  long,  and  the  whole  inclosed  in 
a  frame  of  sheet-iron.  The  sulphur  is  placed  in  the  pans  and 
a  fire  lighted  in  the  furnaces,  melting  the  sulphur,  which  quickly 
ignites.  To  prevent  too  rapid  combustion  baffle  plates  are 
arranged,  and  the  proper  quantity  of  air  is  admitted  through 
adjustable  valves  in  the  furnace-fronts.  The  fumes  of  sulphur 
dioxide  thus  generated  are  collected  and  carried  into  a  reser- 
voir, from  which  they  are  suckeol  by  an  exhaust  fan,  and  are 
thence  forced  through  piping  and  large  flexible  hose  to  the 
apartment  to  be  fumigated. 

The  sulphur-furnace  in  use  at  the  Louisiana  Quarantine 
Station  is  the  same  in  general  principle,  with  the  addition  that 
the  air  supplied  to  the  burning  sulphur  is  aspirated  from  the 
hold  of  the  vessel,  and  then  forced  into  the  furnace. 

Disinfection  by  Germicidal  Solutions.- — The  apparatus  for 
the  use  of  the  disinfecting  solutions  consist  of  a  tank  or  tanks 
elevated  above  the  level  of  the  floor  of  the  wharf  to  a  sufficient 
height  to  force  the  solution  through  a  hose  and  nozzle  to  the 
parts  of  the  ship  to  be  reached.  The  tank  is  to  be  filled  by  a 
steam-pump,  and  the  solution  is  easily  made  by  surmounting 
the  tank  with  a  keg  perforated  by  numerous  holes,  in  which  keg 
the  powdered  bichloride  is  to  be  put,  and  the  water  for  filling 
the  tank  pumped  over  it. 

It  is  a  much  better  plan  to  have  the  bichloride  solution 
distributed  by  means  of  a  special  pump  (made  of  iron  to  pre- 
vent amalgamation),  as,  with  the  pressure  of  the  pump  behind 
it,  it  penetrates  much  more  deeply  into  cracks  and  crevices 
and,  hyfact,  knocks  the  dirt  and  filth  out  of  them. 

5  and  6.  HOSPITALS. — The  propriety  of  having  separate 
hospitals  for  contagious  and  non-contagious  diseases  is  so 
obvious  that  it  need  not  be  dwelt  on  here,  and  the  necessity 
of  a  separate  establishment  for  suspects,  until  the  nature  of 


464  TEXT-BOOK   OF   HYGIENE. 

their  complaint  can  be  positively  made  out,  is  patent  and 
only  in  accord  with  expediency  and  the  'ordinary  instincts  of 
humanity. 

7.  BARRACKS. — Barracks  for  the  detention  of  suspects  are 
not  an  essential  part  of  the  equipment  of  every  quarantine 
station,  but  are  a  necessity  only  at  such  stations  as  are  situated 
at  the  great  ports  of  entry,  which  are  the  ports  of  arrival  of  the 
vast  hordes  of  immigrants  who  seek  our  shores.  Barracks  are 
an  indispensable  adjunct  in  the  management  of  ship-loads  of 
immigrants  suspected  of  being  infected  with  cholera,  typhus 
fever,  and  small-pox,  and  w.ould  be  required  in  the  case  of 
yellow  fever  but  for  the  fact  that  there  is  little  or  no  immigration 
from  the  yellow-fever  zone. 

The  barracks  should  be  commodious,  substantial,  and  yet 
of  simple  and  inexpensive  construction.  They  should  be  well 
ventilated  and  so  arranged  that  every  part  of  the  building  is 
under  constant  surveillance,  and  so  subdivided  that  the  inmates 
are  divided  into  small  groups  and  intercourse  between  the 
groups  prevented.  The  immigration  law  requires  that  the  im- 
migrants shall  be  listed  and  arranged  in  groups  of  thirty,  and  it 
would  be  well  that  this  number  be  preserved  as  the  unit  for 
segregation.  The  barracks  should  be  furnished  with  bunks, 
arranged  in  tiers  one  above  the  other,  and  furnished  with  bed- 
ding of  a  simple  and  inexpensive  character. 

Clothing  of  a  simple  but  sufficient  kind,  and  capable  of 
easy  laundering,  should  be  provided  in  sufficient  quantity  to 
furnish  eacli  inmate  of  the  barracks  with  a  change  while  his  or 
her  own  personal  effects  are  undergoing  the  process  of  disinfec- 
tion. Attached  to  the  barracks  there  should  be  a  kitchen, 
thoroughly  equipped  with  all  the  facilities  for  furnishing  hot 
food  of  a  simple  character  for  the  number  of  inmates  provided 
for  by  the  barracks.  Dining-rooms  should  be  arranged,  and 
special  care  should  be  taken  to  prevent  the  carrying  of  any  food 
into  the  barracks.  It  is  perhaps  needless  to  say  that,  in  the 
barracks,  the  sexes  should  be  separated,  and  the  better  arrange- 


DOMESTIC   QUARANTINE.  465 

ment  is  to  have  two  buildings, — one  for  men  and  one  for  women 
and  children. 

Latrines. — Latrines  of  ample  size  should  be  provided,  and 
should  be  so  arranged  that  all  dejecta  may  be  received  into 
metallic  vessels  containing  a  germicidal  solution  of  acknowl- 
edged potency ;  or,  if  the  dejecta  are  to  be-  received  into  a  sewer, 
there  should  be  some  provision  made  for  their  complete  disin- 
fection prior  to  their  discharge  into  the  sea  or  a  "cess-pool. 

8.  BATH-HOUSE. — Bathing  facilities  are  an  important  part 
of  the  equipment  of  a  quarantine  station  designed  for  the  hand- 
ling of  large  numbers  of  suspects.     The  best  form  of  bath  for 
the  purpose  is  the  shower-  or  rain-  bath,  it  being  more  easily 
managed,  more  expeditious,  and  probably  more  efficacious  than 
the  tub-bath.     The  bath-house  should  be  provided  with  a  room 
for  disrobing,  from  which  the  suspects  will  pass  into  the  bathing- 
stalls  proper,  and  there  receive  a  bath  the  temperature  of  which 
is  under  the  sole  control  of  the  bath-attendant.     From  the  bath 
the  suspect  will  pass  into  a  robing-room,  where  he  will  be  given 
a  suit  of  sterile  clothing,  while  the  clothing  which  was   re- 
moved in  the  disrobing-room  is  carried  by  proper  attendants  to 
the  disinfecting  apparatus,  there  to  be  rendered  safe  by  steriliza- 
tion. 

9.  WATER-SUPPLY. — An  abundant  supply  of  pure  water  is 
riot  only  a  desideratum,  but  a  prime  necessity,  at  all  quarantine 
stations  where  it  is  designed  to  accommodate  cholera  suspects. 
It  would  be  desirable  to  provide  a  supply  of  twenty  gallons  per 
capita  per  day,  and  no  arrangement  will  probably  give  such 
good  results  as  the  sinking  of  an  artesian  well,  if  the  nature  of 
the  soil  and  the  geological  formation  permit.     If  it  is  imprac- 
ticable to  sink  such  a  well,  the   next  best    plan  would  be  to 
arrange  for  the  distillation  or  sterilization,  by  boiling,  of  a  suffi- 
cient quantity  of  water  for  drinking  purposes. 

10.  CREMATORY. — A  crematory  is  a  desirable  part  of  the 
equipment  of  every  quarantine  station,  as  it  admits  of  no  argu- 
ment that  cremation  is  the  best  possible  method  of  disposing  of 


466  TEXT-BOOK    OP   HYGIENE. 

the  bodies  of  those  dead  of  contagious  or  infectious  disease.  In 
addition,  it  would  be  desirable  that  all  garbage  and  waste  about 
a  quarantine  station  be  incinerated  to  prevent  the  possibility  of 
infection. 

11  and  12.  Detailed  description  of  quarters  for  medical 
officers  and  of  laundry  is  unnecessary. 

Having  thus  considered  the  necessities  and  the  desiderata  in 
the  equipment  of  a  quarantine  station,  it  is  now  proper  to  con- 
sider the  regulations  governing  them,  and  for  this  purpose  are 
here  appended  the  regulations  prepared  by  the  Supervising 
Surgeon-General  of  the  Marine-Hospital  Service,  and  pro- 
mulgated by  the  Secretary  of  the.  Treasury  on  April  26,  1894. 
These  regulations  are  to  be  considered  a  minimum  for  the 
stations  under  municipal  arid  State  control,  some  of  which  have 
additional  requirements : — 

QUARANTINE  REGULATIONS  TO  BE  OBSERVED  AT  PORTS  AND  ON  THE 

FRONTIERS  OF  THE  UNITED  STATES. 

i 

PREAMBLE. 

1.  At  or  convenient  to  the  principal  ports  of  the  United   States, 
quarantine  stations  should  l»e  equipped  with  all  appliances  for  the  inspec- 
tion and  treatment  of  vessels,  their  passengers,  crews,  and  cargoes. 

2.  At  all  other  ports  where  such  provisions  have  not  been  made, 
inspection  stations  should  be  maintained. 

3.  An   inspection    service    should    be   maintained   at   every   port 
throughout  the  year. 

4.  At  a  fully-equipped  quarantine  station  there  should  be  adequate 
provision  for  boarding  and  inspection,  apparatus  for  mechanical  cleaning 
of  vessels,  apparatus  for  steam   disinfection,  apparatus  for  disinfection 
with  sulphur  dioxide,  apparatus  for  disinfecting  solutions,  hospitals  for 
contagious  and  doubtful  cases,  detention  barracks  for  suspects,  bathing 
facilities,  crematory,  and  sufficient  supply  of  good  water. 

5.  The  personnel  of  quarantine  stations  in  the  3'ellow-fever  zone 
and  on  fruiters  bound  for  Southern  poi'ts  should  be  immune  against 
yellow  fever. 

6.  At  quarantine  stations  all  articles   liable  to    convey  infection 
should  be  handled  only  by  the  emplo^yes  of  said  station,  unless  the  ser- 
vices of  the  crew  are  indispensable. 


DOMESTIC    QUARANTINE.  467 

7.  Vessels  having  been  treated  at  national  quarantine  stations  that 
are  located  a  considerable  distance  from  the  ports  of  entry  of  said  vessels 
may  be  inspected  by  the  local  quarantine  officer,  and,  if  for  any  sanitary 
reason  it  is  considered  inadvisable  to  admit  the  vessel,  he  should  report 
the  facts  immediately  by  telegraph,  when  possible,  to  the  Supervising 
Surgeon-General  Marine-Hospital  Service,  detaining  the  vessel  pending 
his  action. 

8.  The  following  regulations  are  the  required  minimum  standard, 
and  do  not  prevent  the  addition  of  such  other  rules  as,  for  special  reasons, 
may  be  legally  made  by  State  or  local  authorities. 

ARTICLE   I. INSPECTION. 

1.  Vessels  arriving  at  ports  of  the  United  States  under  the  follow- 
ing conditions  shall  be  inspected  by  a  quarantine  officer  prior  to  entry  : — 

A.  Any  vessel  with  sickness  on  board. 

B.  All  vessels  from  foreign  ports. 

C.  Vessels   from   domestic   ports   where   cholera  or  yellow  fever 
prevails  or  where  small-pox  or  typhus  fever  prevails  in  epidemic  form. 

Exceptions. — Vessels  not  carrying  passengers  on  inland  waters  of 
the  United  States.  Vessels  from  the  Pacific  and  Atlantic  coast  of  Brit- 
ish America,  provided  they  do  not  carry  persons  or  effects  of  persons 
non-resident  in  America  for  the  sixty  days  next  preceding  arrival,  and 
provided  always  that  the  port  of  departure  be  free  from  quarantinable 
disease.  Vessels  from  other  foreign  ports  via  these  excepted  ports  shall 
be  inspected. 

D.  Vessels  from  foreign  ports  carrying  passengers  having  entered 
a  port  of  the  United  States  without  complete  discharge  of  passengers  and 
cargo.     Such  vessels  shall  be  subject  to  a  second  inspection  before  enter- 
ing any  other  port.    Vessels  from  ports  suspected  of  infection  with  yellow 
fever,  having  entered  a  port  north  of  the  southern  boundary  of  Maryland 
without  disinfection,  shall  be  subjected  to  a  second  inspection  before 
entering  any  port  south  of  said  latitude  during  the  quarantine  season  of 
such  port. 

2.  The  inspections  of  vessels  required  by  these  regulations  shall  be 
made  by  daylight,  except  in  case  of  vessels  in  distress. 

3.  In  making  the  inspection  of  a  vessel,  the  bill  of  health  and  clin- 
ical record  of  all  cases  treated  during  the  voyage,  crew  and  passengers' 
lists  and  manifests,  and,  when  necessary,  the  ship's  log  shall  be  examined. 
The  crew  and  passengers  shall  be  mustered  and  examined  and  compared 
with  the  lists  and  manifests,  and  any  discrepancies  investigated. 

4.  No  person  except  the  quarantine  officer,  his  employe's,  United 
States  customs  officers,  or  agents  of  the  vessel,  shall  be  permitted  to 


468  TEXT-BOOK   OF   HYGIENE. 

board  any  vessel  subject  to  quarantine  inspection,  until  after  the  vessel 
has  been  inspected  by  the  quarantine  officer  and  given  its  discharge. 

ARTICLE   II. QUARANTINE. 

1.  For  the  purpose  of  these  regulations,  the  quarantinable  diseases 
are  cholera  (cholerine),  yellow  fever,  small-pox,  typhus  fever,  and  leprosy^ 

2.  Vessels  arriving  under  the  following  conditions  shall  be  placed 
in  quarantine : — 

A.  With  quarantiuable  disease  on  board. 

B.  Having  had  such  on  board  during  the  voyage  or  within  thirty 
days  next  preceding  arrival ;  or,  if  arriving  in  the  quarantine  season, 
having  had  yellow  fever  on  board  after  March  1  of  the  current  year, 
unless  satisfactorily  disinfected  thereafter. 

C.  From  ports  infected  with  cholera,  or  where  typhus  fever  pre- 
vails in  epidemic  form,  coming  directly  or  via  another  foreign  port,  or 
via  United  States  ports,  unless  they  have  complied  with  the  United  States 
quarantine  regulations  for  foreign  ports ;  also  vessels  from  non-infected 
ports,  but  bringing  persons  or  cargo  from  places  infected  with  cholera, 
yellow  fever,  or  where  typhus  fever  prevails  in  epidemic  form,  except  as 
subsequently  noted. 

D.  From  ports  where  yellow  fever  prevails,  unless  disinfected  in 
accordance  with  these   regulations,  and   not  less  than  five  days  have 
elapsed  since  such  disinfection. 

Exceptions. — The  following  exceptions  may  be  made  to  Rules  C 
and  D  with  regard  to  vessels  from  ports  quarantined  against  on  account 
of  yellow  fever  : — 

(a)  Vessels  arriving  during  certain  seasons  of  the  year — to  wit, 
from  November  1  to  May  1 — may  be  admitted  to  entry. 

(6)  Vessels  bound  for  ports  in  the  United  States  north  of  the 
southern  boundary  of  Maryland,  with  good  sanitary  condition  and  his- 
tory, having  had  no  sickness  on  board  at  ports  of  departure  en  route  or 
on  arrival,  provided  they  have  been  five  days  from  last  infected  or  sus- 
pected port,  may  be  allowed  entry  at  port  of  destination.  But  if  said 
vessels  carry  passengers  destined  for  places  sonth  of  this  latitude  the 
baggage  of  said  passengers  shall  be  disinfected. 

In  making  an  inspection  of  a  vessel,  if  from  a  port  where  yellow 
fever  prevails,  and  between  May  1  and  November  1  of  an}7  year,  the 
inspector  shall  ascertain  the  destination  of  each  passenger  thereon,  and 
if  bound  for  places  south  of  the  southern  boundary  of  Maryland  the 
baggage  of  such  passenger  shall  be  disinfected  according  to  the  rules 
for  such  articles  infected  with  yellow  fever.  Such  baggage  shall  be 
labeled. 


DOMESTIC   QUARANTINE.    .  469 

(c)  Vessels  engaged  in  the  fruit  trade  from  ports  declared  safe  for 
this  purpose  by  the  Supervising  Surgeon-General  Marine-Hospital  Ser- 
vice may  be  admitted  to  entry  without  detention,  provided  that  they 
carry  no  passengers  and  have  carried  no  passengers  from  one  port  to 
another  and  have  no  household  effects  or  personal  baggage  in  cargo,  and 
have  complied  with  the  special  rules  and  regulations  made  by  the  Sec- 
retary of  the  Treasury  with  regard  to  vessels  engaged  in  said  trade. 

3.  All  persons  arriving  on  vessels  having  had  small-pox  on  board 
must  be  vaccinated  or  show  satisfactory  evidence  of  recent  vaccination 
or  of  having  had  small-pox,  or  be  detained  in  quarantine  for  not  less 
than  fourteen  days,  and  all  effects  and  compartments  liable  to  convey 
infection  disinfected. 

4.  All  passengers  occupying  apartments  other  than  first  or  second 
cabin  shall  be  vaccinated  prior  to  entry,  unless  they  can  show  that  they 
have  had  small-pox,  or  have  been  recently  successfully  vaccinated,  or  be 
detained  in  quarantine  fourteen  days. 

5.  Vessels  arriving  at  quarantine  with  leprosy  on  board  shall  not 
be  granted  pratique  until  the  leper  with  his  or  her  baggage  has  been 
removed  from  the  vessel  to  the  quarantine  station. 

No  case  of  leprosy  will  be  landed. 

If  the  leper  is  an  alien  passenger  and  the  vessel  is  from  a  foreign 
port,  action  will  be  taken  as  provided  by  the  immigration  laws  and  regu- 
lations of  the  United  States. 

If  the  leper  is  an  alien  and  a  member  of  the  crew  and  the  vessel  is 
from  a  foreign  port,  said  leper  shall  be  detained  at  the  quarantine  at  the 
vessel's  expense,  until  taken  aboard  by  the  same  vessel  when  outward 
bound. 

ARTICLE   III. GENERAL   REQUIREMENTS    AT   QUARANTINES. 

1.  Pilots  bringing  infected  vessels  will  be  detained  in  quarantine  a 
sufficient  time  to  cover  the  period  of  incubation  of  the  disease  for  which 
the  vessel  is  quarantined,  if,  in  the  opinion   of  the  quarantine  officer, 
such  pilots  have  been  exposed  to  infection.     The  dunnage  of  pilots  shall 
be  disinfected  when  necessary. 

2.  No  direct  communication  shall  be  allowed  between  quarantine,  or 
any  vessel  in  quarantine,  and  any  person  or  place  outside,  and  no  com- 
munication except  under  the  supervision  of  the  quarantine  officer. 

3.  No   ballast   shall  be  allowed  to   leave  the  quarantine  station, 
unless  disinfected. 

4.  Where  it  is  impossible  to  disinfect  cargo  in  situ,  it  shall  be  re- 
moved and  disinfected  in  the  manner  provided  for  articles  of  their  class 
in  these  regulations ;  such  articles  to  be  unpacked  and  so  arranged  as  to 


470  TEXT-BOOK    OF    HYGIENE. 

allow  the  disinfectant  used  to  reach  every  part  of  all  surfaces  of  said 
articles. 

5.  Vessels  arriving  at  any  port  of  the  United  States  with  cholera 
or  yellow  fever  aboard  during  the  quarantine  season  shall  be  remanded 
to  an  anchorage  set  apart  for  infected  vessels,  there  to  remain  until  after 
the  discharge  of  the  passengers  and  purification  of  the  vessels. 

6.  All  passenger  baggage  disinfected  under  the  requirements  of 
these  regulations  shall  be  labeled. 

ARTICLE    IV. TREATMENT   IN   QUARANTINE   OF  CHOLERA-INFECTED  VESSELS. 

1.  l  Remove  all  passengers  from  the  vessel  and  all  of  the  crew  (if 
cholera  has  occurred  on  board)  save  those  necessary  to  care  for  her. 
Place  the  sick  in  hospital  and  carefully  isolate  those  specially  suspected. 
Segregate  the  remainder  in  small  groups.     No  communication  shall  be 
held  between  these  groups.     Those  believed  to  be  especially  capable  of 
conveying  infection  must  not  enter  the  barracks  until  they  are  bathed 
and  furnished  with  sterile  clothing ;  nor  shall  any  material  capable  of 
conveying  infection  be  taken  into  the  barracks,  especially  food. 

2.  If  cholera  has  occurred  in  the  steerage,  all  occupants  thereof 
must  be  bathed  and  their  clothing  disinfected. 

3.  At  once  proceed  with  the  disinfection  of  the  hand-baggage. 

4.  All  baggage  and  effects  accompanying  steerage  passengers,  and 
any  other  baggage  or  effects  that  may  have  been  exposed  to  infection, 
must  be  disinfected. 

5.  Such  articles  of  cargo  as  are  liable  to  convey  infection  must  be 
disinfected. 

6.  All  living-apartments  and  furniture  and  such  other  portions  of  a 
vessel  as  are  liable  to  convey  infection  shall  be  disinfected. 

*I.  On  cholera-infected  vessels  the  water-supply  must  be  changed 
without  delay,  the  casks  or  tanks  disinfected  b}-  steam  or  1 0-per-cent.- 
solution  of  potassium  permanganate,  and  after  thorough  rinsing  refilled 
from  a  source  of  undoubted  purity,  or  the  water  supplied  must  have 
been  recently  boiled. 

8.  Nothing  shall  be  thrown  overboard  from  a  cholera-infected  vessel, 
not  even  deck  sweepings.  Such  things  shall  be  burned  in  the  furnace  or 
in  a  place  specially  designated,  but  not  in  the  galley. 

ARTICLE    V. — DISINFECTION,  ETC. 

1.  Holds. — The  disinfection  of  iron  vessels  shall  be  as  follows  : — 
(a)  With  cargo  :  If  cargo  is  so  stowed  as  to  admit  of  disinfection, 
it  and  the  hold  may  be  disinfected  without  breaking  bulk,  except  to  such 

1  It  is  required  only  if  cholera  has  occurred  on  board. 


DOMESTIC   QUARANTINE.  471 

a  degree  as  to  make  disinfection  practicable,  by  sulphur  dioxide,  10  per 
cent,  per  volume  strength,  for  not  less  than  twenty-four  hours'  exposure. 
(6)  Without  cargo:  After  mechanical  cleansing,  the  hold  (1)  to  be 
thoroughly  washed  with  an  acid  solution  of  bichloride  of  mercury  1  to 
800  (mercury  1  part,  hydrochloric  acid  2  parts,  water  800  parts),  applied 
under  pressure  to  all  surfaces  by  means  of  a  hose  ;  (2)  by  sulphur  dioxide, 
10  per  cent,  per  volume  strength,  for  twenty-four  hours. 

2.  Steerage  and  Forecastle. — When  possible  to  obtain  it — 

(a)  The  steerage  and  forecastle  shall  be  disinfected  by  steam ;  the 
temperature  in  all  parts  of  these  compartments  to  be  not  less  than  100° 
C.  for  not  less  than  thirty  minutes  after  such  temperature  has  been 
reached. 

(6)  When  steam  cannot  be  obtained  these  compartinents  shall  be 
treated  in  the  same  manner  as  required  in  the  disinfection  of  the  empty 
hold. 

3.  All  bedding  and  furnishings  of  the  steerage  and  forecastle  to  be 
left  in  place  during  the  disinfection  by  steam. 

If  steam  disinfection  of  steerage  is  not  used,  such  articles  must  be 
removed  under  the  strictest  sanitary  precautions  for  disinfection  by  steam 
or  burning. 

4.  The  bedding,  fabrics,  and  carpets  should  be  removed  and  disin- 
fected by  steam  or  by  boiling.     After  thorough  mechanical  cleansing  the 
woodwork  and  all  other  exposed  surfaces  shall  be  washed  with  an  acid 
solution  of  bichloride  of  mercury  1  to  1000,  or  a  3-per-cent.  solution  of" 
pure  carbolic  acid.    Fabrics  which  cannot  be  removed  shall  be  thoroughly 
saturated  with  a  solution  of  bichloride  of  mercury  1  to  1000,  or  a  3-per- 
cent, solution  of  pure  carbolic  acid. 

5.  The  water  ballast  of  a  vessel  coming  from  a  cholera-infected  port 
should  be  discharged  at  sea,  or,  if  discharged  in  fresh  or  brackish  water, 
must  be  previously  disinfected.     The  tanks  to  be  flushed  and  refilled 
with  sea-water  or  disinfected. 

6.  For  a  wooden  vessel  the  treatment  is  as  above,  except  that  ex- 
posure of  the  hold  and  living-apartments  to  sulphur  dioxide,  10-per-cent. 
volume,  must  precede  the  other  treatment.     This  exposure  must  be,  for 
the  hold,  forty-eight  hours,  and  for  living-apartments  twelve  hours. 

7.  All  solid  ballast  to  be  discharged  or  disinfected  previous  to  dis- 
infection of  hold.     All  ballast  discharged  in  fresh  water  to  be  disinfected 
by  saturation  with,  or  immersion  in,  an  acid  solution  of  bichloride  of 
mercury  1  to  800.     Clear,  hard,  close-grained  rock  may  be  permitted  to 
remain  on  board,  but  only  after  disinfection  by  immersion  in  an  acid  solu- 
tion (1  to  800)  of  bichloride  of  mercury.     Ballast  removed  from  vessels 
must  not  be  taken  from  the  quarantine  station. 


472  TEXT-BOOK    OF    HYGIENE. 

ARTICLE    VI. — DETENTION   OP   PASSENGERS   ON    ACCOUNT    OF    CHOLERA. 

1.  The  people  detained  shall  be  inspected  by  the  physician  twice 
daily,  and  be  under  his  constant  surveillance,  and  no  intercourse  will  be 
allowed  between  different  groups  while  in  quarantine. 

2.  No  direct  communication  shall  be  allowed  between  any  person 
detained  in  quarantine  and  any  one  not  in  quarantine,  except  through  the 
quarantine  officer  or,  by  his  order,  through  his  agents. 

3.  The  water-  and  food-  supply  will  be  strictly  guarded  to  prevent 
contamination,  and  issued  to  each  group  separately. 

4.  Food  of  a  simple  character,  sufficient  in  quantity,  thoroughly 
cooked,  shall  be  issued  to  those  detained  in  quarantine.     No  fruit  shall 
be  permitted. 

5.  Cleanliness  of  quarters  and  of  persons  shall  be  enjoined  and 
enforced  daily.     Disinfection  shall  be  used  where  there  is  any  possibility 
of  infection. 

6.  Water-closets,  urinals,  privies,  or  troughs  shall  be  provided,  and 
their  contents  disinfected  before  they  are  discharged, 

7.  In  any  group  in  which  cholera  appears,  the  sick  will  be  imme- 
diately isolated  in  hospital,  and  the  remaining  persons  in  the  group  shall 
be  bathed  and  their  effects  be  disinfected ;  then  removed  to  other  quarters, 
if  possible,  and  the  compartment  disinfected. 

8.  No  direct  communication  shall  be  allowed  between  the  physician 
and  attendants  of  the  hospital  and  those  detained  in  quarantine. 

No  persons  shall  be  discharged  from  quarantine  until  five  days  have 
elapsed  since  the  last  exposure  to  infection  and  a  final  disinfection  of 
such  effects  as  were  taken  to  barracks. 

No  convalescent  from  cholera  shall  be  discharged  from  quaran- 
tine until  after  a  sufficient  time  has  elapsed  to  insure  his  freedom  from 
infection.1 

9.  The  bod}r  of  no  person  dead  of  cholera  shall  be  allowed  to  pass 
through  quarantine.     The  body  should  be  cremated  if  practicable.     If 
not,  it  should  be  wrapped,  without  preliminary  washing,  in  a  sheet  satu- 
rated with  a  solution  of  bichloride  of  mercury  1   to  500,  and  buried, 
surrounded  by  caustic  lime. 

ARTICLE    VII. DISINFECTION    OF   PERSONAL   EFFECTS   OF   PASSENGERS   AND 

CREW    AND   CARGO. 

1.  Clothing,  bedding,  and  articles  not  injured  by  steam  shall  be 
disinfected — 

(a)  By  exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  has  been  reached. 

1  To  be  determined  by  bacteriological  examination. 


DOMESTIC   QUARANTINE.  473 

(6)  By  boiling  for  fifteen  minutes ;  all  articles  to  be  submerged, 
(c)  By  a  thorough  saturation  in  a  solution  of  bichloride  of  mer- 
cury 1  to  1000,  and  allowed  to  dry  before  washing. 

2.  Articles  injured  by  steam  (rubber,  leather,  etc.)  and  containers, 
to  the  disinfection  of  which  steam  is  inapplicable,  shall  be  disinfected  by 
thoroughly  wetting  all  surfaces  with  a  solution  of  bichloride  of  mercury 
1  to  800,  or  a  5-per-cent.  solution  of  carbolic  acid,  and  allowed  to  dry  in 
open  air. 

3.  Cooking  and  eating  utensils,  by  immersing  in  boiling  water  or 
steam. 

4.  All  rags  and  old  textile  fabrics  used  in  the  manufacture  of  paper, 
and  all  old  gunny,  old  jute,  etc.,  fit  only  for  remanufacture,  gathered,  col- 
lected, packed,  or  handled  in  any  port  or  place  where  cholera  (cholerine) 
or  yellow  fever  exists,  or  where  small-pox  or  typhus  fever  prevails  in 
epidemic  form,  and  for  thirty  days  after  the   port  or  place  shall  be 
officially  declared  free  from  such  diseases  or  epidemic,  shall  be  denied 
entry  into  any  port  of  the  United  States. 

5.  No  rags  or  old  textile  fabrics  used  in  the  manufacture  of  paper, 
or  articles  enumerated  in  the  preceding  paragraph,  which  have  not  been 
disinfected  in  accordance  with  Article  "VII,  paragraph  3,  of  the  "  United 
States  Quarantine  Regulations  for  Foreign  Ports,"  shall  be  admitted 
into  the  United  States. 

(Old  jute  bags,  old  cotton  bags,  old  rope,  new  cotton  and   linen 
cuttings  from  factories,  not  included.) 

ARTICLE    VIII. TREATMENT    OP   VESSELS    INFECTED    OR    SUSPECTED   OF 

BEING  INFECTED  WITH   YELLOW    FEVER. 

1.  Where  practicable,  at  once  remove  the  sick  to  hospital ;  remove 
and  isolate  all  persons  not  required  for  the  care  of  the  vessel. 

2.  If  the  hold  is  deemed  infected,  there  shall  be  a  preliminary  dis- 
infection as  hereinafter  provided. 

3.  The  bilge  should  be  cleansed  with  sea-water,  if  possible,  before 
disinfection,  and  the  hold  rendered  mechanically  clean. 

4.  All  ballast,  except  close-grained,  hard  rock,  must  be  discharged. 
This  may  be  retained  aboard  if  disinfected  by  immersion  in  an  acid  solu- 
tion of  bichloride  of  mercury  1  to  800. 

5.  After  discharge  or  disinfection  of  ballast  the  vessel  should  be 
disinfected. 

6.  If  it  is  so  stowed  as  to  admit  of  disinfection,  the  cargo  and  the 
hold  may  be  disinfected  without  breaking  bulk,  except  to  such  a  degree 
as  to  render  disinfection  practicable. 

It  shall  be  as  follows  : — 


474  TEXT-BOOK   OF   HYGIENE. 

Holds  to  be  treated  with  sulphur  dioxide,  10-per-cent.  strength  per 
volume,  forty-eight  hours'  exposure  for  iron  vessels,  seventy-two  hours' 
exposure  for  wooden  vessels. 

7.  Empty  holds  to  be  disinfected  as  follows: — 

(a)  If  of  iron,  by  sulphur-dioxide  gas,  10-per-cent.  strength  per 
volume,  for  twelve   hours'  exposure,  followed  by  washing  with  an  acid 
solution  of  bichloride  of  mercury  1  to  800,  applied  under  pressure  to  all 
surfaces  by  means  of  a  hose. 

(b)  If  of  wood,  by  the  same  methods  as  the  preceding,  save  that 
exposure  to  sulphur-dioxide  gas  shall  be  for  forty-eight  hours  ;  air-strnkes 
to  be  open. 

8.  Cabin,  forecastle,  etc.,  after   mechanical  cleansing,  to  be   first 
treated  with  sulphur  dioxide,  not  less  than  6-per-cent.  strength  per  vol- 
ume, twenty -four  hours'  exposure.     Then  (after  cleansing  with  water,  if 
desired)  wash  all  exposed  surfaces  with  a  solution  of  bichloride  of  mer- 
cury 1  to  800,  or  3-per-cent.  pure  carbolic  acid. 

9.  Clothing,  bedding,  and  all  fabrics  which  can  be  removed,  not 
injured  by  steam,  shall  be  disinfected — 

(a)  By  exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  has  been  reached. 

(6)  By  boiling  for  fifteen  minutes ;  all  articles  to  be  submerged. 

(c)  By  a  thorough  saturation  in  a  solution  of  bichloride  of  mercury 
1  to  1000,  and  allowed  to  dry  before  washing. 

10.  Articles  injured  by  steam  (rubber,  leather,  etc.)  and  containers, 
to  the  disinfection  of  which  steam  is  inapplicable,  shall  be  disinfected  by  (a) 
thoroughly  wetting  all  surfaces  with  a  solution  of  bichloride  of  mercury 
1  to  800,  or  a  5-per-cent.  solution  of  pure  carbolic  acid,  and  allowed  to 
dry  in  open  air;  or  (b)  by  exposure  to  the  sulphur  fumigation,  in  cabin, 
forecastle,  or  hold. 

11.  The  personnel  of  the  vessel  shall  be  detained  five  days  from 
completion  of  the  disinfection. 

12.  If  the  vessel  has  been  disinfected  under  the  supervision  of  an 
accredited  medical  officer  of  the  United  States  at  the  port  of  departure, 
the  period  of  quarantine  may  date  from  completion  of  such  disinfection, 
and  shall  not  be  less  than  five  days. 

ARTICLE   IX. — PASSENGER   TRAFFIC. 

Passenger  traffic  may  be  allowed  during  the  qiiarantine  season  from 
any  port  infected  with  yellow  fever  to  any  port  of  the  United  States 
south  of  the  southern  boundary  of  Maryland,  under  the  following  con- 
ditions : — 

(a)  Vessels  to  be  of  iron  and  clean  immediately  prior  to  taking  on 
passengers.  » 


DOMESTIC   QUARANTINE.  475 

(6)  The  vessel  must  lie  at  moorings  in  the  open  harbor  and  not  ap- 
proach the  wharves,  nor  must  the  crew  be  allowed  ashore  at  the  port  of 
departure. 

(c)  All  passengers  and  crew  must  be  immune  to  yellow  fever,  and 
so  certified  by  the  United  States  medical  officer.1 

(d)  All  baggage  which  has  not  been  disinfected  at  the  port  of  de- 
parture by  the  United  States  medical  officer,  or  which -is  not  in  bond  for 
points  north  of  the  southern  boundary  of  Maryland,  shall  be  disinfected 
at  the  quarantine  at  the  port  of  arrival ;  no  bedding  or  household  effects 
to  be  allowed  to  enter. 

ARTICLE  X. — MISCELLANEOUS. 

1.  The  treatment  of  vessels  infected  with  typhus  fever  shall  be  the 
same  as  that'  prescribed  for  yellow  fever. 

2.  The  detention  of  passengers  and  crew  for  small-pox  and  typhus 
fever  shall  cover  the  period   of  incubation  of  the  disease,  the  time  of 
detention  to  commence  from  the  date  of  last  exposure  ;  typhus  fever,  not 
less  than  twenty  days  ;  small-pox,  not  less  than  fourteen  days. 

3.  Vessels  detained  at  any  national  quarantine  will  be  subject  to 
such  additional  rules  and  regulations  as  may  be  promulgated  from  time 
to  time  by  the  Supervising  Surgeon-General. 

4.  The  following  is  the  form  of  certificate  which  shall  be  issued 
to  the  vessel  by  the  health  officer  when  she  is  released  from  quaran- 
tine : — 


189—. 


I  CERTIFY  that ,  of ,  from ,  has  in  all  respects  complied  with  the 

quarantine  regulations  prescribed  by  the  Secretary  of  the  Treasury,  and  that  in  my 
opinion  she  will  not  convey  quarantinable  disease.  Said  vessel  is  this  day  granted  free 
pratique. 

"~~> 
Health  (Quarantine)  Officer, 

Port  of . 

ARTICLE   XI. — INSPECTION   OP   STATE   AND  LOCAL  QUARANTINES. 

In  the  performance  of  the  duties  imposed  upon  him  by  the  act  of 
February  15,  1893,  the  Supervising  Surgeon-General  of  the  Marine-Hos- 
pital Service  shall,  from  time  to  time,  personally  or  through  a  duly- 
detailed  officer  of  the  Marine-Hospital  Service,  inspect  the  maritime 
quarantines  of  the  United  States,  State  and  loc^.1,  as  well  as  national,  for 
the  purpose  of  ascertaining  whether  the 'quarantine  regulations  prescribed 
by  the  Secretary  of  the  Treasury  have  been  or  are  being  complied  with. 

1  The  evidence  of  immunity  which  may  be  accepted  by  the  sanitary  inspector  is  :  First 
Proof  of  continued  residence  in  an  endemic  focus  of  yellow  fever  for  ten  years.  Second. 
Proof  of  previous  attack  of  yellow  fever. 


476  TEXT-BOOK   OF   HYGIENE. 

The  Supervising  Surgeon-General,  or  the  officer  detailed  by  him  as  in- 
spector, shall  at  his  discretion  visit  any  incoming  vessel,  or  any  vessel 
detained  in  quarantine,  and  all  portions  of  the  quarantine  establishment, 
for  the  aforementioned  purpose,  and  with  a  view  to  certifying,  if  need  be, 
that  the  regulations  have  been,  or  are,  being  enforced. 

ARTICLE    XII. — CANADIAN    AND   MEXICAN    FRONTIERS. 

1.  When  practicable,  alien  immigrants  arriving  at  Canadian  and 
Mexican  ports,  destined  for  the  United  States,  shall  be  inspected  at  the 
port  of  arrival  by  the  United  States  consular  or  medical  officer,  and  be 
subjected  to  the  same  sanitary  restrictions  as  are  called  for  by  the  rules 
and  regulations  governing  United  States  ports. 

•  2.  Inspection  cards  will  be  issued,  by  the  consular  or  United  States 
medical  officer  at  the  port  of  arrival,  to  all  such  alien  immigrants,  and 
labels  affixed  to  their  baggage,  as  is  required  in  the  case  of  those  coming 
direct  from  foreign  ports  to  any 'port  of  the  United  States. 

3.  Whenever  alien  immigrants  are  not  inspected  at  the  port  of 
arrival  by  the  United  States  consular  or  medical  officer,  they  shall  enter 
the  United  States  through   certain  designated  places  on  the  frontier, 
where  they  shall  be  inspected  for  the  purpose  of  preventing  the  intro- 
duction  of  quarantinable  disease.     This   inspection   shall   be   held   by 
daylight. 

4.  If  any  person  be  found  suffering  from  a  quarantinable  disease, 
or  presumably  infected,  he  shall  be  denied  entry  so  long  as  danger  of 
conveying  the  infection  exists. 

5.  Any  baggage  or  other  effects  believed  to  be  infected  shall  be 
refused  entry  until  made  safe  by  a  proper  disinfection. 

6.  Persons  coming  from  localities  where  small-pox  is  prevailing  in 
epidemic  form   shall  not  be  allowed  entry  without  vaccination,  unless 
they  are  protected   by  a  previous  attack  of  the   disease  or  a  recent 
successful  vaccination. 

7.  Persons  coming  from  localities  where  typhus  fever  prevails  in 
epidemic  form  shall  not  be  allowed   entry  until  they  have  been  away 
from  such  locality  fonrteen  days  and  their  baggage  disinfected. 

8.  During  the  quarantine  season  persons  coming  from  places  where 
yellow  fever  prevails  will  not  be  permitted  to  enter  until  they  have  been 
away  from  such  locality  five  days  and  their  baggage  has  been  disinfected. 
But  persons  immune  to  yellow  fever  will  not  be  detained. 

9.  No  common  carrier  which   is   infected,  or  suspected  of  being 
infected,  shall  be  allowed  to  enter  the  United  States  until  after  such 
measures  have  been  taken  as  will  render  it  safe. 

10.  Articles  of  merchandise,  personal  effects,  etc.,  which  are  capable 


MANAGEMENT   OF   A    QUARANTINE   STATION.  477 

of  conveying  infection,  and  which  are  presumably  infected,  shall  not  be 
allowed  entry  into  the  United  States  until  after  disinfection. 

11.  The  methods  of  disinfection  shall  be  those  prescribed  in  the 
Rules  and  Regulations  made  for  the  maritime  quarantines  of  the  United 
States. 

Immigrants  who,  with  their  baggage,  have  been  inspected  at  a  port 
of  the  United  States  by  a  quarantine  officer  upon  landing,  will  be  exempt 
from  further  quarantine  inspection  when  re-entering  the  United  States 
from  Canada,  unless  there  is  reason  to  believe  that  disease  has  developed 
among  such  immigrants  since  such  landing  and  inspection. 

It  is  the  intention  of  the  act  of  February  15,  1893,  under 
which  these  regulations  were  framed,  to  have  them  act  uni- 
formly and  without  discrimination  against  any  place,  and  at  the 
same  time  to  not  interfere  with  the  operation  of  any  additional 
regulations  imposed  by  State  or  local  authority. 

MANAGEMENT   OF   A    QUARANTINE    STATION. 

Inspection. — Upon  the  arrival  of  a  vessel  at  a  quarantine 
station,  during  the  active  quarantine  season,  she  should  be 
boarded  without  delay,  and  the  following  general  routine  fol- 
lowed, with  such  modifications  as  may  be  demanded  by  the 
local  conditions  or  dictated  by  the  experience  of  the  quarantine 
officer.  In  the  event  of  the  arrival  of  several  vessels  at  the 
same  time,  they  should,  as  a  rule,  be  boarded  as  nearly  as  pos- 
sible in  the  order  of  their  arrival,  the  rule  of  "  first  come,  first 
served  "  being  observed ;  though  it  may  be  remarked  that,  in 
the  event  of  the  arrival,  at  nearly  the  same  time,  of  a  vessel 
carrying  passengers  and  one  carrying  cargo  only,  there  will 
usually  be  little  opposition  on  the  part  of  ship-masters  if  the 
passenger-ship  is  inspected  first.  Arrived  on  board,  it  is 
well  to  demand  the  immediate  attendance  of  the  master,  not 
only  from  the  fact  that  all  information  must  be  sought  from 
him,  but  to  impress  all  concerned  with  the  fact  that  the  author- 
ity of  the  boarding-officer  is,  for  the  time,  absolute.  The  master 
should  then  be  required  to  produce  for  inspection  his  bills  of 
health,  the  ship's  manifest,  and  the  crew-  and  passenger-  lists, 


478  TEXT-BOOK   OF   HYGIENE. 

if  the  ship  carry  passengers.  These  should  be  carefully  scru- 
tinized, the  number  of  crew  and  passengers  being  noted  or 
borne  in  mind,  and  note  being  made  of  any  articles  of  cargo 
that  come  within  the  proscription  of  the  regulations.  All 
special  consular  certificates  bearing  on  doubtful  articles  of  cargo 
had  better  be  looked  into  at  this  time.  A  careful  inspection  of 
the  ship  should  now  follow,  particular  attention  being  paid  to 
the  condition  of  the  living-apartments  of  the  officers  and  crew, 
as  their  condition  of  cleanliness  or  the  reverse  sometimes  forms 
an  important  index  to  the  cleanliness  of  the  whole  ship.  The 
hatches  should  be  removed,  and  such  portions  of  the  cargo  as 
come  directly  under  them  be  subjected  to  scrutiny.  If  the 
vessel  is  in  ballast,  the  hold  should  be  entered,  explored,  and 
mental  note  made  of  the  condition  of  the  ship's  inner  planking 
or  skin,  whether  dry  and  sound  or  rotten  and  damp.  If  pos- 
sible, a  limber  plank  should  be  lifted,  and  the  condition  of  the 
bilges  noted.  In  the  comparatively  inaccessible  places  fore  and 
aft  there  will  likely  be  found  deposits- of  trash  and  filth,  and 
the  chain-lockers  should  be  carefully  examined  to  see  whether 
the  cables  have  been  properly  washed  prior  to  stowing,  as  there 
is  good  reason  to  believe  that  the  harbor-mud  of  certain  ports, 
notably  Havana,  is  dangerous.  The  inspection  of  the  ship 
proper  completed,  the  inspection  of  persons  should  be  entered 
into. 

Every  person  borne  upon  the  ship's  papers  as  passenger  or 
member  of  the  crew  should  be  personally  seen  by  the  boarding- 
officer  or  his  assistant,  and  no  excuse  whatever  should  be  taken 
for  an  absence  from  this  muster.  Take  nothing  for  granted, 
and  compel  the  master  to  explain  any  discrepancies  between  the 
lists  and  the  actual  number  presenting  themselves  for  examina- 
tion. The  decision  must  now  be  reached  whether  the  vessel 
goes  free  under  the  regulations  or  is  to  be  detained  in  quaran- 
tine. If  the  former,  the  certificate  of  inspection  is  filled  out, 
and  the  master  notified  that  he  is  at  liberty  to  proceed.  If  the 
latter,  the  vessel  is  directed  to  a  suitable  anchorage,  and  the 


MANAGEMENT    OF    A   QUARANTINE    STATION.  479 

yellow  quarantine  flag  is  hoisted  at  the  foremast-head.  Quaran- 
tine procedures  proper  now  begin,  and  much  depends  on  the 
nature  of  the  disease  quarantined  against ;  the  nature  and  con- 
dition of  the  ship,  whether  light,  in  ballast,  or  loaded.  If  there 
are  passengers  on  board,  these  are  landed,  bathed,  and  assigned 
to  quarters  in  the  barracks'.  The  vessel  is  laid  alongside  of  the 
wharf  and  the  disinfecting  processes  prescribed  by  the  regula- 
tions entered  upon. 

The  disinfection  of  iron  and  wooden  vessels,  while  depend- 
ing on  the  same  general  principles,  differs  essentially  in  detail. 
This  is  illustrated  in  the  following  article  on  the  "  Disinfection 
of  Wooden  Vessels,"  by  Surgeon  H.  R.  Carter,  published  in  the 
"Annual  Report  of  the  Marine-Hospital  Service  for  1892"  : — 

SOME  POINTS  IN  THE  DISINFECTION  OF  WOODEN  VESSELS 
FOR  YELLOW  FEVER. 

There  are  many  points  of  difference  to  a  quarantine  officer  between 
wooden  sailing-vessels  and  steam-ships.  The  former  lie  longer  in  the 
ports  of  clearance  ;  the  crews  have  communication  with  the  shore ;  there 
are  more  deserters,  and  consequently  more  men  are  shipped  at  these 
ports  to  take  their  places.  All  of  these  things  affect  a  vessel's  sanitary 
standing. 

The  points,  however,  to  which  it  is  desired  to  call  attention  at 
present  are  (l)the  treatment  of  ballast  and  (2)  the  disinfection  of  the 
hold,  and  both  apply  only  to  wooden  sailing-vessels.1 

TREATMENT   OF  BALLAST. 

This  ballast  is  regarded  differently  by  different  boards  of  health, 
but  by  all  as  at  least  "  suspicious." 

Florida  regulations  require  the  discharge  of  all  ballast  from  infected 
ports  before  a  vessel  is  allowed  to  enter.  If  the  vessel  is  judged  infected 
the  ballast  aboard  must  be  removed  at  the  refuge  station  to  which  she  is 
sent,  and  new  ballast  not  from  an  infected  port  substituted  if  any  is 
needed.  Disinfection  of  ballast  is  not  recognized. 

Louisiana2  allows  it  to  be  wet  in  situ  with  bichloride  solution  and 
to  remain  aboard  during  the  fumigation  ;  then  it  is  considered  safe  (1891). 

'Save  schooners  ami  American-built  square-rigged  craft  of  small  burden  (brigantines 
and  barkentines  mainly),  practically  all  sailing-vessels  from  yellow-fever  ports  come  in  ballast. 

3  The  recommendation  for  a  ballast  lighter  in  the  report  of  the  Louisiana  quarantine 
physician,  1890,  shows  that  this  method  was  not  perfectly  satisfactory  to  him. 


480  TEXT-BOOK   OF    HYGIENE. 

Savannah,  which  ascribes  an  epidemic  to  ballast,  and  Charleston,  while 
requiring  all  ballast  to  be  discharged  at  their  own  quarantine  stations, 
yet  allow  "  dipped  "  ballast  from  vessels  that  have  been  infected  to  be 
there  discharged  along  with  ballast  from  non-infected  vessels,  thus  agree- 
ing to  its  harmlessness.  A  vessel  of  which  the  ballast  may  be  infected 
is  not  allowed  at  either  of  these  quarantine  stations. 

Mobile  and  Mississippi  ports  allow  "  dipped  "  ballast  to  enter  port, 
and,  if  need  be,  to  remain  aboard  or  to  be  discharged  ashore. 

Is  ballast  often  a  source  of  infection?  From  Havana,  yes.  From 
Brazilian  ports,  if  of  rock,  no.  It  depends  mainly  on  its  material  and 
whence  procured. 

From  Havana,  Cienfuegos,  and  some  other  Cuban  ports  comes  a 
fairly-good  white  stone ;  a  soft,  crumbly,  blue  rock,  containing  talc  and 
mixed  with  clay  ;  and  what  is  called  by  masters  and  in  the  manifest 
"  sand,"  but  which  contains  so  much  old  plaster,  broken  tiles,  and  bricks 
that  "  rubbish  "  would  seem  a  better  name  for  it. 

Twice  this  last  and  once  (two  cases)  the  blue-stone  ballast  is  be- 
lieved to  have  been  the  source  of  yellow  fever  in  vessels  at  the  Gulf 
Quarantine  since  1887. 

Rio,  Santos,  and  the  Brazilian  ports  south  of  Para  send  a  gneiss 
or  granite  rock,  not  hard  for  its  kind,  but  far  better  than  the  best  Cuban 
ballast,  and  a  loam  due  to  its  decomposition.  This  is  also  called  "  sand  " 
in  the  manifests,  and  if  dry  may  be  taken  for  sand  ;  but  it  is  really  a  loam, 
setting  like  cement  when  wetted.  It  is  alkaline.  Few  vessels  for  Gulf 
or  South  Atlantic  ports  bring  this  "  sand,"  as  it  is  objected  to  by  most 
quarantine  officers,  and  the  masters  of  vessels  are  suspicious  of  it  them- 
selves, and  when  wet  it  makes  a  very  dirty  ship. 

From  Rio  both  kinds  come  from  high  hills  or  mountains  across  the 
bay  from  the  city,  and  the  locality  is  considered  to  be  a  healthy  one,  but 
in  1889  I  was  informed  that  there  was  yellow  fever  among  the  quarry  men 
as  bad  as  elsewhere. 

Even  with  what  is  called  rock  ballast  there  is  much  small  stuff  and 
dust,  especialty  under  the  hatches  where  it  is  taken  in.  This  forms  a 
compact  mass  with  the  larger  stones  under  the  hatches,  there  being  fre- 
quently one  hundred  to  one  hundred  and  fifty  tons  of  this  close  ballast 
in  a  vessel.  The  finest  of  it,  however,  is  only  granite  sand,  undecom- 
posed,  and  does  not  cohere  with  water.1 

The  writer  is  cognizant  of  only  one  case  of  3rellow  fever  (British 
bark  Chippewa,  1890),  presumably  due  to  Brazilian  ballast,  and  this  may 
well  have  been  from  another  source.  Nevertheless,  in  such  rock  ballast 

1  In  1889,  when  there  was  a  very  bad  epidemic  in  Rio,  the  rock  ballast  from  that  port  was 
nearly  all  small  stuff.  The  government  was  using  large  rock  on  some  public  works,  and  the 
vessels  took  for  ballast  what  was  left  on  the  lighters. 


MANAGEMENT   OF    A   QUARANTINE    STATION.  481 

at  the  Gulf  Quarantine  have  been  found  rotten  boards,  articles  of  clothing, 
and  (once)  faecal  matter,  all  at  such  a  depth  in  the  ballast  that  they  must 
have  come  aboard  at  the  port  of  departure  (Rio,  in  these  instances). 

Ballast  from  Colon  is,  for  rock  ballast,  the  worst  possible,  and,  if 
infected,  the  best  fitted  to  preserve  infection.  It  is  a  friable,  porous 
stone  (coral?),  filled  with  slimy  mud,  a  fresh  fracture  staining  water. 
Many  cases  of  malarial  (Chagres)  fever  were  seen,  certainly  due  to  work- 
ing in  this  ballast,  but  no  yellow  fever  has  been  ascribed  to  it  the  \  :i.  t 
four  years.  Probably  little  has  been  at  Colon  during  this  time.  Cases 
of  yellow  fever  were  ascribed  to  ballast  from  Vera  Cruz  at  the  Gulf 
Quarantine  (French  ship  Emil  Postel,  1891). 

Regarding  ballast  from  infected  ports,  then,  as  "  suspicious "  or 
"  probably  infected,"  it  may  be  either  (a)  discharged  or  (6)  disinfected. 
When  possible,  the  former  method  is,  of  course,  preferable  on  the  ground 
of  economy,  the  ballast  being  discharged  by  lighter  or  otherwise  in  about 
eight  feet  of  water.  Unfortunately,  most  square-rigged  sailing-vessels 
require  ballast  for  their  own  safety,  especially  when  going  from  outlying 
refuge  stations  to  their  loading  ports  ;  and  while  ballast-logs  may  be  sul>- 
stituted  in  certain  cases,  yet  in  many  others,  the  majority,  they  are  inap- 
plicable. It  is,  therefore,  in  general,  impossible  to  leave  such  a  vessel 
empty  of  all  ballast  at  a  refuge  station.  Enough  close-grained,  picked 
rock  (no  small  stuff  or  trash  being  allowed)  to  trim  the  vessel  and  render 
her  safe  may  be  disinfected  and  retained  aboard.  This  disinfection  is 
accomplished  by  dipping  each  piece  in  a  solution  (acid)  of  HgCl3,  1  to 
800  or  1000,  as  it  is  trimmed  in  the  vessel's  hold.  The  rock  is  immersed 
completely  in  the  solution,  and  stays  wet  with  it  some  time,  besides 
being  continually  wetted  by  the  solution  running  down  from  those  piled 
on  it.  Although  some  boards  of  health  will  not  allow  any  ballast  from 
an  infected  port  or  vessel  to  enter  their  jurisdiction,  yet  it  is  believed 
that  this  dipped  stone,  hard  and  clean,  is  safe.  Certainly,  if  washing  a 
wooden,  more  or  less  splintered  keelson  with  bichloride  solution  renders 
it  safe  to  enter  port  with  the  vessel,  the  immersion  of  a  granite  rock  in 
the  same  solution  should  give  it,  the  rock,  the  same  immunity.  Indeed, 
the  risk  of  conveying  infection  by  picked  rock,  even  without  the  disinfec- 
tion, must  be  exceedingly  small. 

This  is  not  the  slow  process  it  may  seem,  but  is  obviously  slower 
than  wetting  the  ballast  with  a  hose  as  it  lies,  and  a  number  of  experi- 
ments were  made  at  the  Gulf  Quarantine  by  wetting  rock  ballast  with 
bichloride  solution,  opening  the  pile  and  testing  individual  stones  for 
mercury.  The  solution  was  served  through  a  1^-inch  hose  by  a  strong 
steam-pump  under  full  pressure,  and  observations  were  made  aboard  the 
ships  Sardinian,  Chrysolite,  Prince  Regent,  and  Curlew,  and  barks 

31 


482  TEXT-BOOK    OF    HYGIENE. 

President,  Mabine,  and  others.  In  every  case  stones  were  found  some 
part  of  which  gave  no  reaction  for  mercury.  As  a  rule,  the  parts  in  con- 
tact with  other  stones  had  been  wet,  while  the  parts  not  so  in  contact 
quite  frequently  did  not  show  the  reaction. 

A  consequence  of  this  is  that  where  ballast  is  first  fumigated  and 
then  wet  down  with  bichloride  solution  there  is  some  probability  of  the 
S03  reaching  the  parts  of  the  stones  not  wet  by  the  bichloride.  This  is 
less  apt  to  take  place  if  the  fumigation  follow  the  wetting  down. 

It  seemed  as  if  the  liquid  followed  certain  paths  in  passing  through 
the  ballast,  and  after  a  certain  amount  of  solution  had  been  used  no  pro- 
portionate increase  of  wetting  was  observed  by  increasing  the  use  of  the 
solution.  In  these  experiments  the  solution  was  used  considerably  in 
excess  of  what  is  usually  used  in  wetting  down  ballast. 

Letters  from  masters  of  vessels  which  had  had  their  ballast  so 
treated  elsewhere  state  that  the  ballast  (rock  and  fine  stuff)  was,  after  the 
process,  in  good  condition  for  handling  except  near  the  surface  and  next 
the  keelson ;  that  no  sand  was  carried  into  the  bilge,  and  that  "  most  of 
the  fine  stuff  was  as  nice  and  dry  as  if  the  ballast  had  not  been  wet  down." 
The  same  statements  have  been  made  verbally  by  several  masters  of 
vessels. 

It  seems  doubtful,  then,  if  it  be  possible  to  certainly  wet  all  of  a 
vessel's  rock  ballast  in  situ  by  an  amount  of  water  short  of  submerging 
it,  and  that,  if  the  ballast  be  infected,  this  method  is  less  sure  than  that 
of  dipping. 

Also,  if  ballast  be  thoroughly  wetted,  it  is  obvious  that  much  sand 
must  pass  through  the  ceiling,  stopping  the  limbers,  fouling  the  pumps, 
and  doing  a  certain  amount  of  damage  to  the  vessel,  and  requiring  con- 
siderable work  of  the  crew  to  correct  it. 

Where  this  method  was  tried  with  sand  it  seemed  to  wet  all  of  it ;  at 
least  every  piece  selected  in  the  two  vessels  experimented  on  yielded  the 
mercurial  reaction.  The  sand  was  leveled  so  as  to  be  as  thin  as  possible, 
ditches  dug  across  the  hold,  and  then  filled  with  the  solution.  After  this 
soaked  in,  the  ridges  were  turned  into  the  ditches  and  the  place  where 
the  ridges  had  been  ditched,  and  these  filled  with  solution  of  bichloride. 
To  wet  the  sand  thoroughly  required  from  one-twentieth  to  one-twelfth 
of  its  weight  of  water. 

Colon  stone  is  probabty  not  disinfected  by  immersion  in  the  solu- 
tion of  bichloride  unless  the  time  of  immersion  be  considerably  prolonged 
— hours  or  days  ;  nor  was  it  ever  judged  safe  to  attempt  to  disinfect  the 
rubbish  ballast  from  Havana. 

Of  course,  the  ballast  is  to  be  disinfected  as  far  as  possible  in  situ 
before  discharging  any,  when  it  is  believed  that  moving  it  will  endanger 


MANAGEMENT   OF   A   QUARANTINE   STATION.  483 

the  workers.  But  wet  ballast  is  exceedingly  disagreeable  to  handle  and 
is  injurious  to  the  vessel,  and,  indeed,  all  work  about  a  presumably 
infected  vessel  should  be  done  by  the  acclimated  quarantine  crew. 

DISINFECTION    OF   HOLD. 

In  1888,  1889,  and  1890  a  series  of  rough  experiments  were  made 
at  the  Gulf  Quarantine  to  determine  the  penetrating  power  of  S03  in  suf- 
ficient amount  to  destroy  animal  life — ants  and  cockroaches.  These  were 
made  in  the  holds  of  vessels  undergoing  disinfection,  so  as  to  be  under 
the  same  conditions  as  those  in  which  the  gas  was  used  in  practice. 
These  cannot  be  given  in  detail  here,  but  they  showed  that  a  film  of 
water  (sea-water)  from  three  to  five  inches  thick  presented  such  a  barrier 
to  the  passage  of  the  gas  that  in  forty-eight  hours  it  would  not  destroy 
insect  life  beyond  it;  that  clothes  soaked  in  sea- water  thick  enough  to 
stay  wet  were  equally  impenetrable,  while  the  same  clothes  dry  allowed 
insects  to  be  killed  within  them ;  that  rotten  pine-wood,  if  reasonably 
dry,  was  penetrated  four  inches  with  the  grain  and  less  than  two  inches 
across  the  grain ;  that  this  same  wood  soaked  in  sea-water  was  impervious 
for  even  one  inch  with  the  grain. 

Dr.  Kinyoun  informs  me  that  a  10-per-cent.  atmosphere  of  SO2  (10- 
per-cent.  volume)  will  destroy  certain  micro-organisms  through  six  inches 
of  rotten  wood  containing  16  per  cent,  of  moisture, — I  presume,  with  the 
grain. 

Now,  in  the  hold  of  a  vessel  rotten  wood  is  most  apt  to  be  found,  if 
anywhere,  in  the  timbers  in  the  ill-ventilated  spaces  between  the  skin  and 
ceiling,  at  the  ends  of  the  deck  beams,  at  the  water-line  near  the  stern, 
but  in  every  case  between  the  skin  and  ceiling.  In  spite  of  air-strakes 
and  ventihitors,  the  communication  between  these  spaces  and  the  open 
hold  is  very  meagre,  and  is  rendered  still  more  so  by  the  "  stop  waters  " 
in  all  American  vessels, — pieces  fitted  in  between  the  timbers  to  keep  the 
bilge-water  from  splashing  up  on  the  cargo  when  the  vessel  lays  over  in 
sailing.  Obviously,  then,  if  the  hold  of  a  vessel  be  infected  the  infection 
is  most  probably  in  the  rotten  wood,  a  favorite  nidus  in  ill-ventilated 
spaces,  and  it  is  ditlicult  to  reach. 

It  has  been  the  habit  to  use  a  large  amount  of  bichloride  solution 
and  to  leave  it  in  the  vessel  until  she  leaves  quarantine,  so  as  to  splash 
about  as  she  rolls  and  so.ik  into  her  wood  as  thoroughly  as  possible. 
Nevertheless,  it  is  obvious  that  no  liquid  can  be  depended  on  to  reach 
and  saturate  all  parts  of  the  woodwork  under  the  ceiling.  A  gaseous 
disinfectant  is  necessary  if  there  be  infection  in  these  places,  and  the 
problem  is  to  make  it  eflicient.  After  opening  every  air-strake, — they 
are  generally  closed  by  battens  on  arrival  in  quarantine, — the  main 


484  TEXT-BOOK   OF   HYGIENE. 

dependence  for  reaching  these  spaces  must  be  by  the  cracks  between  the 
planks  in  the  ceiling.  Now,  if  the  vessel  be  fumigated  immediately  after 
she  is  washed  down  with  bichloride  solution,  and  the  washing  is  done  as 
it  should  be,  all  of  these  cracks  and  all  of  the  small  interstices,  where 
beams,  etc.,  come  together,  are  filled  by  films  of  this  solution,  through 
which  this  gas  cannot  pass,  or  passes  with  difficulty,  and  the  places 
which  most  need  disinfection  cannot  get  it. 

This  to  me  seems  a  more  serious  objection  to  using  the  bichloride 
solution  before  fumigating,  in  wooden  vessels,  than  the  fact  that  HgCl2 
is  partially  converted  into  Hg2Cl3  by  the  SO3,  although  this  certainly 
occurs  in  pans  holding  bichloride  in  solution  exposed  in  the  hold  of  a 
vessel  undergoing  fumigation. 

Also,  to  enable  the  gas  to  diffuse  itself  through  the  cracks  into 
these  spaces  in  sufficient  proportion  to  be  efficient  as  a  disinfectant,  it  is 
necessary  to  have  it  in  the  hold  a  considerable  time.  At  the  Gulf  Quar- 
antine the  hold  was  closed  for  forty-eight  hours,  and  occasionally  seventy- 
two  hours.  This  w,as  done  to  allow  for  this  diffusion,  and  not  because  it 
was  believed  that  so  long  a  contact  of  the  gas  with  any  infecting  organ- 
isms was  desirable. 

It  seems  right  to  state  here  that  infection  of  the  hold  of  a  vessel, 
not  meaning  the  ballast,  is  not  common  in  vessels  which  have  the  houses 
on  deck,  and  the  contents  of  the  hold,  the  ballast,  is  less  commonly 
infected  than  the  dunnage  of  the  forecastle  and  cabin. 

To  determine  what  part  of  a  vessel  is  infected,  beyond  a  mere  prob- 
ability, is  not  usually  possible  ;  indeed,  to  determine  if  a  vessel  be  "  prob- 
ably infected  "  is  at  times  far  from  easy. 

Officially  this  is  determined  by  the  regulations  of  the  quarantine 
station  or  port  of  entry,  but  a  vessel  may  be  officially  judged  infected 
and  (rightly)  submitted  to  disinfection  when,  in  point  of  fact,  the  prob- 
ability of  her  being  infected  is  slight;  and  (for  Middle  Atlantic  ports) 
the  converse  may  occur.  The  fact  of  a  vessel  having  had  yellow  fever 
aboard,  especially  if  only  at  the  port  of  clearance  and  not  en  route,  may 
not  be  sufficient  to  class  her  as  "  probably  infected."  The  circumstances 
of  the  attacks  may  be  such  as  to  show  that  they  were  contracted  ashore, 
and  that  the  sick  men  did  not  contaminate  the  vessel ;  or  there  may  be 
evidence  to  show  that,  although  there  was  a  source  of  infection  aboard 
the  vessel,  it  is  no  longer  existing. 

For  an  instance  of  the  first,  among  many  instances,  the  American 
ship  Fawne  had  six  cases  of  yellow  fever  developing  aboard  her  while  at 
Rio  in  1891,  but  in  every  case  it  developed  in  seamen  who,  the  log 
showed,  had  returned  from  shore  less  than  thirty-six  hours  before,  and 
there  had  been  no  development  of  fever  among  a  considerable  number, 


TREATMENT    OF   YELLOW-FEVER    VESSELS.  485 

twelve  or  fourteen,  of  unacclimated  seamen  living  in  the  same  forecastle 
and  working  over  every  part  of  the  ship  for  about  fifty  days  since  the 
last  case  aboard.  From  this  vessel  the  sick  were  sent  to  hospital  the 
first  day  of  their  sickness,  with  all  of  their  loose  dunnage  with  them. 
No  supplies  taken  aboard,  no  men  shipped,  and  only  the  master  went 
ashore  after  the  fever  developed.  This  vessel  was  probably  not  infected 
at  any  time. 

As  an  illustration  of  the  second,  far  less  common  than  the  first, 
the  British  ship  Prince  Frederick  was  infected  at  Rio  in  1889.  A 
number  of  cases — thirteen,  I  think — developed  aboard  her  under  con- 
ditions which  showed  that  they  were  contracted  aboard, — i.e.,  in  men 
who  had  had  no  recent  communication  ashore,  and  one  case  en  route. 
She  came  up  short-handed  to  Barbados,  having  en  route  destroyed  some 
dunnage — that  of  the  dead — and  aired  all  of  the  rest,  keeping  it  on  lines 
in  the  sun  all  of  every  day  when  possible ;  cleaned  and  ventilated  the 
houses  above  decks,  and  ventilated  the  hold.  The  weather  the  whole 
time  was  bright,  with  light  winds.  At  Barbados  the  crew  was  strength- 
ened by  shipping  new  men,  among  them  seven  English  lads,  fresh  young 
fellows  from  16  to  21  years  old,  who  had  never  been  south  before, — the 
most  perfect  temoines  for  yellow  fever, — yet  no  case  developed  among 
them,  even  when  they  cleaned  ship. 

This  vessel  undoubtedly  had  a  source  of  infection  aboard,  but  was 
freed  from  it,  probably,  in  consequence  of  the  ventilation  and  other 
measures  adopted. 

If  there  be  dunnage  packed  away  aboard  which  was  infected  when 
packed,  no  time-limit  can  be  relied  on  for  removing  the  infection,  while 
persistent  airing  in  bright  weather  will  probably  do  so.  Even  washing 
in  cold  water,  as  sailors  do,  seems  to  be  sufficient  to  disinfect  fabrics 
from  yellow  fever. 

Several  cases  are  known  where  aired  or  washed  clothing  was 
handled  with  impunity  by  a  number  of  unacclimated  persons,  from  which 
yellow  fever  had  been  contracted  by  those  who  unpacked  or  washed  it,  and 
no  case  of  infection  from  well-aired  clothing  has  ever  been  known  to  the 
writer.  Moisture  seems  necessary  for  the  infection  to  keep  its  efficiency. 

It  is  not,  of  course,  intended  that  airing,  etc.,  should  ever  be  relied 
on  for  the  disinfection  of  fabrics ;  only  to  show  that  some  vessels  may 
clear  themselves  of  infection  by  this  method  and  ventilation. 

TREATMENT   OF   YELLOW-FEVER   VESSELS. 

It  is  fortunate  that  vessels  from  yellow-fever  ports  rarely 
have  any  considerable  number  of  passengers  on  board,  and  that 


486  TEXT-BOOK   OF   HYGIENE. 

our  efforts  have  therefore  to  be  directed  only  to  the  cleansing  of 
the  ship,  the  care  of  those  actually  sick  with  the  disease  at  the 
time  of  arrival,  and  the  detention,  under  observation  for  a  period 
of  five  days,  of  those  exposed  to  the  infection.  The  cleansing 
of  the  ship,  whether  of  wood  or  iron,  is  specifically  treated  of 
in  the  regulations ;  the  disinfection  of  the  cargo  presents  few 
difficulties,  as  the  cargo  is  usually  either  sugar  or  coffee,  gen- 
erally packed  in  bags,  and  admitting  of  thorough  disinfection 
by  the  application  of  sulphur  dioxide  in  the  strength  and  for 
the  time  prescribed  in  the  regulations.  Several  years  ago  the 
Louisiana  State  Board  of  Health  issued  a  circular  to  shippers 
recommending  that  all  cargoes  of  sugar  and  coffee  be  stowed 
with  a  shaft  or  tunnel  under  each  hatchway,  reaching  from  the 
upper  tiers  of  the  cargo  to  the  keelson  of  the  vessel.  This  shaft 
admits  of  the  entrance  of  the  sulphur-hose,  and  the  gas,  forced 
in  under  pressure,  has  free  access  to  the  envelopes  of  every 
package,  which  it  penetrates  to  the  depth  of  three-quarters  of 
an  inch  or  more,  thus  insuring  thorough  disinfection  of  the  cargo 
without  the  necessity  of  breaking  bulk,  and  at  a  minimum  of 
time  and  expense. 

The  sick  should  be  at  once  carried  to  the  infected  hospital, 
if  their  condition  permit  it,  and  the  remainder  of  the  crew  and 
passengers  inspected  twice  daily  until  the  time  of  danger  is 
passed  and  the  vessel  is  discharged  from  quarantine. 

Vessels  from  yellow-fever  ports  generally  arrive  at  quar- 
antine stations  either  light  or  in  ballast.  The  treatment  of 
these  vessels  is  so  fully  dealt  with  in  the  foregoing  article  of 
Surgeon  Carter  that  further  comment  is  unnecessary. 

TREATMENT   OF   CHOLERA   VESSELS. 

In  the  event  of  the  arrival  of  a  ship  actually  infected  with 
Asiatic  cholera,  or  suspected  of  such  infection,  a  much  more 
difficult  problem  confronts  the  quarantine  officer,  for  the  condi- 
tions differ  widely  from  those  obtaining  in  the  case  of  the  yellow- 
fever  ship.  In  a  majority  of  cases  the  cholera  ship  carries  a 


TREATMENT   OF   CHOLERA   VESSELS.  487 

large  number  of  passengers,  a  great  majority  of  whom  belong 
to  the  immigrant  class,  and  the  difficulty  of  handling  these  is 
largely  increased  by  the  carelessness  of  their  personal  habits, 
their  ignorance  and  disregard  of  the  first  laws  of  personal 
hygiene,  and  the  discomfort,  crowding,  and  bad  sanitary  con- 
dition of  their  quarters  on  board  ship.  Here  many  sources  of 
danger  must  be  looked  into,  and  it  is  almost  certain  that  a 
disregard  of  any  one  of  them  will  be  followed  by  a  terrible 
retribution  in  the  shape  of  new  outbreaks  of  the  disease. 

The  first  thing  to  be  done  in  the  treatment  of  a  cholera- 
infected  ship  is  to  remove  her  human  freight,  and  this  should 
be  done  as  rapidly  as  is  consistent  with  safety.  The  occupants 
of  the  compartment  of  the  ship  in  which  cholera  has  appeared 
should  receive  our  first  and  most  careful  attention.  They  must 
be  landed  at  once,  bathed  with  all  possible  precaution  and 
thoroughness,  furnished  with  clean,  sterile  clothing,  and  isolated 
in  the  barracks  and  regarded  as  especially  dangerous.  Those 
actually  sick  with  the  disease  should  be  at  once  carried  to  the 
contagious  hospital,  and  those  sick  with  any  complaint  whatever 
isolated  in  the  suspect  hospital  pending  the  determination  of  the 
actual  nature  of  their  disease. 

The  foregoing  applies  particularly  to  the  steerage  passen- 
gers. The  question  of  the  treatment  of  the  cabin  and  saloon 
passengers  is  one  that  will  call  for  all  the  tact  and  ingenuity  of 
the  quarantine  officer,  and  even  then  he  will  be  liable  to  savage 
criticism  and  censure  through  the  friends  of  the  cabin  passen- 
gers detained.  It  must  be  remembered  that  these  passengers 
are  luxuriously  lodged  and  catered  for  with  every  delicate  atten- 
tion that  ingenuity  and  long  experience,  sharpened  by  active 
competition,  can  suggest.  On  board  ship  they  are  most  care- 
fully guarded  from  intrusion  on  the  part  of  the  steerage  passen- 
gers, and,  in  fact,  are  as  nearly  on  a  separate  ship  as  possible. 
Is  it  always  necessary  to  subject  these  people  to  the  inconveni- 
ences and  possible  hardships  that  are  inseparable  from  a  deten- 
tion in  quarantine  barracks'?  The  answer  is  that  each  case 


488  TEXT-BOOK   OF    HYGIENE. 

must  be  decided  on  its  individual  merits,  and  much  will  depend 
on  the  extent  to  which  the  ship  seems  infected,  the  seeming 
source  of  the  infection,  and  the  facilities  which  exist  on  board 
ship  for  maintaining  a  sharp  line  of  demarkation  between  the 
steerage  and  saloon. 

If,  on  investigation,  it  seem  that  the  choleraic  outbreak  is 
due  to  infected  food  smuggled  on  board  by  the  emigrants,  to 
infection  probably  brought  aboard  in  the  hand-baggage  of  the 
same  class  of  passengers ;  if,  in  fine,  it  would  seem  to  be  due 
to  conditions  limited  to  the  steerage,  it  might  seem  to  be  the 
part  of  wisdom  to  leave  the  cabin  passengers  in  their  luxurious 
quarters  while  the  processes  of  disinfection  and  detention  were 
in  progress.  If,  on  the  contrary,  the  infection  seem  to  be  due 
to  a  polluted  ship's  water-supply;  if  there  have  been  any  cases 
of  diarrhceal  disease  among  the  cabin  passengers ;  if  the  infec- 
tion seem  to  be  distributed  equally  to  the  steerage  and  to  the 
saloon,  then  all  must  be  landed  alike,  and  undergo  barrack 
detention,  at  least,  until  the  disinfection  of  the  ship  is  thoroughly 
complete. 

The  barracks  for  the  cabin  passengers  must,  of  course,  be 
of  a  different  character  from  those  provided  for  the  steerage. 
They  must  be  subdivided  into  small  rooms,  and,  instead  of 
bunks,  must  be  furnished  with  comfortable  cots,  bedding,  and 
simple,  but  neat  and  efficient,  toilet  facilities.  A  separate 
kitchen  and  table  must  be  provided  for  this  class  of  passengers, 
and  the  whole  situation  may  be  summed  up  by  saying  that  the 
relative  difference  on  shipboard  should  be  preserved  on  shore 
during  the  detention  in  quarantine. 

SPECIAL   MEASURES    AGAINST   CHOLERA. 

Other  features  of  quarantine  administration  are  well  ex- 
pressed in  the  following  extract  from  the  editorial  pages  of  the 
Philadelphia  Medical  News  of  October  15,  1887,  showing  the 
measures  necessary  to  extinguish  an  incipient  epidemic  of  cholera 
and  to  prevent  its  spivad.  Such  measures  are  as  follow: — 


SPECIAL   MEASURES   AGAINST   CHOLERA.  489 

(a)  Speedy  recognition  and  isolation  of  the  sick ;  their  proper 
treatment ;  absolute  and  rapid  destruction  of  the  infectious  agent  of  the 
disease,  not  only  in  the  dejecta  and  vomit,  but  also  in  clothing,  bedding, 
and  in  or  upon  whatever  else  it  finds  a  resting-place. 

(6)  The  convalescents  should  remain  isolated  from  the  healthy  as 
long  as  their  stools  possibly  contain  any  of  the  infecting  agent ;  before 
mingling  again  with  the  well  they  should  be  immersed  in  a  disinfecting 
bath,  and  afterward  be  clothed  from  the  skin  outward  with  perfectly- 
clean  vestments,  which  cannot  possibly  contain  any  of  the  infectious 
material. 

(c)  The  dead  should  be  well  wrapped  in  cloth  thoroughly  saturated 
in  a  solution   of  corrosive  sublimate   (1   to  500),  and,  without  delay, 
cortege,  or  lengthy  ceremonial,  buried  near  the  place  of  death  in  a  deep 
grave,  remote  as  possible  from  water  which  may,  under  any  circum- 
stances, be  used  for  drinking,  washing,  culinary,  or  other  domestic  pur 
poses.     (Cremation,  of  course,  is  by  far  the  safest  way  of  disposing  of 
cholera  cadavers.) 

(d)  Those  handling  the  sick  or  the  dead  should  be  careful  to  dis- 
infect their  hands  and  soiled  clothing  at  once,  and  especially  before  touch- 
ing articles  of  food,  drinking,  or  culinary  vessels. 

(e)  In  the  case  of  maritime  quarantine,  the  well  should  be  disem- 
barked and  placed  under  observation  in  quarters  spacious  enough  to 
avoid  crowding,  and  so  well  appointed  and  furnished  that  none  will  suffer 
real  hardships. 

(/)  Once  having  reached  the  station,  those  under  observation 
should  be  separated  in  groups  of  not  more  than  twelve  to  twenty-four, 
and  the  various  groups  should,  under  no  pretext,  intermingle.  The  quar- 
ters for  each  group  should  afford  stationary  lavatories  and  water-closets 
in  perfect  working  condition,  adequate  to  the  needs  of  the  individuals 
constituting  the  group,  and  supplied  with  proper  means  of  disinfection. 
There  should  be  a  bed  raised  above  the  floor,  proper  coverings,  and  a 
chair  for  each  member  of  the  group,  each  person  being  required  to  use 
only  his  own  bed.  There  should  be  a  common  table  of  sufficient  size  to 
seat  around  it  all  the  members  of  the  group,  who  should  be  served  their 
meals  from  a  central  kitchen,  and  with  table-furniture  belonging  to  the 
station  and  cleaned  by  the  common  kitchen  scullions. 

(g)  Drinking-water,  free  from  possible  contamination  and  of  the  best 
quality,  should  be  distributed  in  the  quarters  of  each  group  as  it  is 
needed,  and  in  such  a  manner  that  it  is  received  in  drinking-cups  only. 
There  should  be  no  water-buckets  or  other  large  vessels  in  which  hand- 
kerchiefs, small  vestments,  children's  diapers,  etc.,  can  be  washed  by  the 
members  of  any  group. 


490  TEXT-BOOK   OF    HYGIENE. 

(h)  Immediately  after  being  separated  into  groups  in  their  respect- 
ive quarters,  every  person  under  observation  should  be  obliged  to  strip 
and  get  into  a  bath  (a  disinfecting  one  is  preferable),  and  afterward  be 
clothed  with  fresh,  clean  vestments  from  the  skin  outward.  Every  article 
of  clothing  previously  worn  should  be  taken  away  and  properly  disin- 
fected. 

(i)  Then  all  of  the  personal  effects  should  be  at  once  removed  to  a 
separate  building,  washed  (if  possible),  and  thoroughly  disinfected,  or, 
if  necessary,  destroyed.  After  disinfection  they  should  be  temporarily 
returned  to  the  members  of  groups,  when  occasion  requires  a  further 
change  of  clothing. 

(jfc)  Under  no  circumstances  whatever  should  washing  of  clothing 
by  those  under  observation  be  permitted.  All  used  clothing  should  be 
first  thoroughly  disinfected  (by  boiling,  when  possible),  and  then  should 
be  cleansed,  the  disinfection  and  washing  being  done  by  a  sufficiently 
trained  and  absolutely  reliable  corps  of  employe's  supplied  with  adequate 
appliances. 

(I)  All  those  under  observation  should  be  mustered  in  their  own 
quarters,  and  be  subjected  to  a  close  medical  inspection,  while  on  their 
feet,  at  least  twice  every  day,  in  order  to  discover  and  isolate,  as  soon 
as.  possible,  new  cases  which  may  develop ;  and,  of  course,  the  clothing 
and  bedding  of  these  new  cases  should  be  treated  without  delay  in  the 
manner  already  mentioned.  In  the  mean  time,  a  watch  should  be  set 
over  the  water-closets  for  the  purpose  of  discovering  cases  of  diarrrhcea, 
and,  when  discovered,  such  cases  should  be  temporarily  separated  from 
the  rest.  They  should  receive  judicious  medical  attention  at  once,  and 
precautions  should  be  taken  as  if  they  were  undoubted  but  mild  cases  of 
cholera. 

(m)  The  quarters  should  be  kept  thoroughly  clean,  and  every  sur- 
face upon  which  infectious  material  could  possibly  be  deposited,  includ- 
ing the  floors,  should  be  washed  with  a  strong  disinfectant  twice  daily, 
and  oftener  when  necessary.  Evacuations  from  the  bowels  should  be 
passed  into  a  strong  disinfectant ;  the  hopper  of  the  closet  should 
be  then  flushed  and  finally  drenched  with  a  quantity  of  the  same  disin- 
fectant. 

(n)  For  the  proper  attention  to  the  sick,  there  should  be  two  or 
more  competent  and  experienced  physicians,  assisted  by  a  sufficient 
corps  of  intelligent  and  efficient  nurses,  with  hours  of  duty  so  arranged 
that  a  physician,  with  a  sufficient  number  of  nurses,  shall  be  in  constant 
attendance  in  the  wards  of  the  hospital. 

(o)  For  the  prompt  recognition  and  separation  of  new  cases,  their 
temporary  medical  attention,  the  proper  treatment  of  discovered  cases 


REGULATIONS  FOR  CHOLERA  CAMP.  491 

of  diarrhoea  or  cholerine  and  of  other  maladies,  and  the  immediate  cor- 
rection of  every  insanitary  practice  or  condition  by  constant,  vigilant, 
and  intelligent  supervision,  there  should  be  at  least  two  or  more  compe- 
tent and  experienced  physicians,  with  hours  of  service  so  arranged  that 
a  pli3Tsician  is  on  duty  night  and  day  among  those  under  observation  ; 
and  he  should  have,  subject  to  his  orders  at  any  and  every  moment,  a 
sufficient  and  efficient  corps  of  nurses  and  laborers  to  carry  out  properly 
and  promptly  his  directions. 

(p)  In  order  to  prevent  the  intermingling  of  the  various  groups,  to 
enforce  obedience  and  order,  and  to  make  it  absolutely  impossible  for  the 
quarantined  and  their  personal  effects  to  have  any  communication  with 
the  exterior,  a  well-organized  and  sufficiently  large  police  corps  should 
patrol  the  borders  of  the  stations  and  the  buildings  day  and  night. 

(q)  Any  group  among  whom  there  have  developed  no  new  cases  of 
cholera  or  of  choleraic  diarrhoea,  during  the  preceding  eight  or  ten  days, 
may  be  regarded  as  harmless,  and  allowed  to  leave  quarantine  after  each 
one  is  finally  immersed  in  a  disinfecting  bath  and  re-clothed  with  clean 
garments  from  the  skin  outward,  the  garments  removed  being  destroyed 
or  thoroughly  disinfected  and  cleansed,  as  already  indicated. 

As  yet  no  reference  has  been  made  to  the  crew,  ship,  and  cargo. 
What  has  been  said  of  the  treatment  of  those  under  observation  applies 
to  every  one  of  the  ship's  inhabitants.  The  observation,  isolation,  and 
cleansing  of  the  crew  and  their  effects  could  safely  be  performed  aboard 
ship  if  necessary.  The  ship  should  be  thoroughly  cleansed  and  disin- 
fected, particular  attention  being  given  to  the  quarters  of  the  emigrants 
and  crew. 

The  following  general  regulations  were  promulgated  for 
the  government  of  camps  and  barracks  for  the  detention  of 
cholera  suspects  during  the  summer  of  1892: — 

REGULATIONS  FOR  CHOLERA  CAMP. 

(Prepared  in  the  Marine-Hospital  Bureau.) 

The  surgeon  in  command  of  the  quarantine  camp  to  have 
absolute  authority  over  the  police  and  sanitary  regulations  of 
the  camp,  and  to  see  that  they  are  obeyed. 

Camp  to  be  divided  into  two  divisions, — detention  and 
hospital.  Former  for  housing  of  suspected  cases  and  well  per- 
sons from  infected  localities  and  the  latter  for  treatment  of  sick. 


492  TEXT-BOOK   OF   HYGIENE. 

DETENTION   CAMP. 

1.  Persons  destined  for  this  camp  to  be  assigned  to  specific 
quarters  in  tents.     First  to  be  subjected  to  disinfecting  bath, 
and  clothed  afterward  with  fresh  vestments.     Not  to  leave  this 
camp  except  by  permission  or  order  of  surgeon  in  command. 

2.  Persons  in  detention  camp  to  be  inspected  twice  daily 
or  oftener  by  medical  officer  or  assistant,  while  standing,  to 
ascertain  any  new  cases  which  may  develop. 

3.  New  cases  of  cholera  in  detention  camp  to  be  immedi- 
ately transferred  to  hospital  camp  for  treatment,  and  all  their 
effects   disinfected,   as    well   as    the  tent   in  which   they  may 
occur. 

4.  Guards  to  patrol  detention  camp  night  and  day,  to  pre- 
vent intercourse  between  the  two  divisions  of  the  camp. 

5.  Water-supply  for  entire  camp  to  be  boiled  for  drinking. 
To  be  dealt  out  to  each  person  in  cups  or  glasses  for  potable 
purposes.     May  be  acidulated  with  diluted   hydrochloric  acid 
under  supervision  of  a  medical  officer. 

6.  If  there  be  room,  the  detention  camp  to  be  segregated 
into  divisions  of  not  more  than  twenty  persons.     No  intercom- 
munication should  be  permitted  between  the  groups. 

7.  All  clothing  removed  from  persons  entering  detention 
camp  to  be  subjected  to  steam  heat  (unmixed  with  air),  not  less 
than  100°  C.  (212°  R),  for  one-half  hour,  or  boiling  for  one 
hour.     Leather  and  rubber  goods  to  be  immersed  in  3-per-cent. 
carbolic-acid  solution  until  thoroughly  saturated. 

8.  The  washing  of  clothing  not  to  be  permitted  by  the 
detained  persons  under  any  pretext.     After  above  disinfection, 
all  laundry-work  to  be   then  done  by  the  force  of  employes. 
The  clothing  of  detained  suspects  should  be  kept  in  separate 
building    after    disinfection,    and    re-issued    as    required    for 
change. 

9.  Cleanliness  and  disinfection  of  quarters  and  person  to 
be  enjoined  and  enforced  daily.     Disinfectants  to  be  used  where 
there  is  any  possibility  of  infection. 


HOSPITAL  CAMP.  493 

10.  At  the  expiration  of  five  days,  if  no  case  of  cholera 
or  choleraic  diarrhoea  has  developed  in  a  given  group  segre- 
gated as  above,  those  composing  the  group  may  be  discharged, 
after  a  final  disinfection  of  person  and  clothing. 

11.  All  water-closets,  urinals,  privies,  or  troughs  should  be 
provided  with  latrines  similar  to  those  of  the  cholera  camp, 
and  means  should  be  provided  for  their  thorough  disinfection 
before   their   contents   are   discharged   into   pits  of  unslacked 
lime. 

12.  Food  issued  shall  be  simple,  thoroughly  cooked,  and 
served  at  stated  hours.     No  fruit  permitted. 

HOSPITAL   CAMP. 

1.  Day  sick-calls  at  8  A.M.  and  4  P.M.  ;  oftener,  if  necessary. 
Night  call,  12  P.M.,  by  night  physician;  oftener,  if  circum- 
stances require. 

2.  There  shall  be  one  nurse  for  every  hospital  tent,  who 
shall  be  on  duty  in  six-hour  watches. 

Night  nurses  according  to  circumstances.  Female  nurses 
for  cases  occurring  in  that  sex. 

Nurses  should  be  instructed  in  the  necessity  of  personal 
hygiene  and  the  sources  of  infection. 

3.  Vomited  matter  and  stools  to  be  received  into  earthen 
vessels,  and  at  once  disinfected  with  3-per-cent.  solution  of  car- 
bolic acid  or  1  to  500  HgCl2  combined  with  2  parts  of  HC1  to 
each  part  of  HgCl2 ;  then  thrown  into  a  pit  of  unslacked  lime, 
or  discharged  into  the  sea. 

4.  All  soiled  linen  or  clothing  that  cannot  be  disinfected  to 
be  immediately  destroyed  by  burning. 

5.  When  death  occurs,  body  to  be  immediately  buried, 
swathed  in  sheets  saturated  with  1  to  500  HgCl2.     Place  of 
interment  to  be  selected  to  avoid  contamination  of  water-supply. 

6.  No  persons  having  personal  contact  with  the  sick  or 
dead  shall  leave  the  hospital  camp  without  practicing  disinfec- 
tion, as  specified  above. 


494  TEXT-BOOK   OF   HYGIENE. 

DANGER   FROM   FLIES   IN   QUARANTINE. 

In  this  article  it  has  been  suggested  that  all  dejecta  and 
vomited  matters  of  cholera  patients  be  received  into  vessels  con- 
taining an  efficient  germicidal  solution ;  and  this  is  not  only  for 
the  reason  that  the  said  dejecta  and  vomited  matters  may  infect 
any  one  who  comes  into  inadvertent  contact  with  them,  but  has 
an  important  bearing  on  the  health  of  those  who  are  resident 
in  the  neighborhood  of  the  quarantine  station.  It  has  been 
abundantly  proved  that  the  ordinary  house-fly  is  capable  of  con- 
veying in  its  intestinal  tract,  for  a  considerable  length  of  time, 
living  and  active  cholera  spirilla.  Knowing  how  constantly 
flies  deposit  their  ordure  on  articles  of  food,  it  can  easily  be  seen 
how  great  a  menace  to  public  health  would  be  engendered  by 
allowing  stools  containing  the  bacilli  to  remain  without  instant 
disinfection.  The  safer  plan  is,  therefore,  to  not  trust  to  subse- 
quent disinfection,  which  might  be  overlooked  in  the  press  of 
other  matters,  but  to  receive  the  dejecta  into  the  germicidal 
solution  so  that  no  time  will  be  lost  and  no  chances  of  infection 
may  remain. 

THE  NATIONAL  QUARANTINE  SERVICE. 

The  national  quarantine  stations,  eleven  in  number,  are 
established  at  points  of  danger  where  either  local  quarantine  is 
defective  or  where,  by  reason  of  peculiar  advantage  in  location, 
protection  is  afforded  to  several  States  by  one  station.  These 
stations  are  as  follow: — 

Delaware  Breakwater  Quarantine  Station,  Lewes,  Del. ; 
Reedy  Island  Quarantine  Station,  Delaware  River;  Cape 
Charles  Quarantine  Station,  Fisherman's  Island,  Va, ;  South 
Atlantic  Quarantine  Station,  Blackbeard  Island,  Sapelo  Sound, 
Georgia ;  Brunswick  Quarantine  Station,  Brunswick,  Ga. ; 
Key  West  Quarantine  Station,  Tortugas  Islands,  Fla. ;  Gulf 
Quarantine  Station.  Ship  Island,  Miss. ;  San  Diego  Quarantine 
Station,  San  Diego,  California ;  San  Francisco  Quarantine  Sta- 
tion, Angel  Island,  San  Francisco  Bay,  California ;  and  Port 


THE   NATIONAL   QUARANTINE   SERVICE.  495 

Townsend  Quarantine  Station,  Port  Townsend,  Washington. 
A  station  has  been  authorized  by  Congress  and  will  be  erected 
at  Southport,  N.  C. 

DESCRIPTION  OF   THE   NATIONAL   QUARANTINE    STATIONS  ON 
DELAWARE  BAY  AND   RIVER. 

It  may  prove  of  interest  to  briefly  describe  a  national 
quarantine  station,  and  -no  better  example  can  be  found  than 
the  stations  at  Delaware  Breakwater  and  at  Reedy  Island, 
Delaware  River.  These  stations,  while  in  a  measure  separate 
and  distinct,  are  intended  to  work  in  connection  with  each 
other  and  to  afford  complete  protection  against  the  importation 
of  contagious  and  infectious  disease  through  the  medium  of  the 
commerce  which  seeks  the  port  of  Philadelphia  and  the  ports 
of  entry  on  Delaware  Bay,  and  situated  in  the  States  of  Dela- 
ware, New  Jersey,  and  Pennsylvania.  At  the  station  at 
Delaware  Breakwater,  which  is  situated  at  the  mouth  of  Dela- 
ware Bay  and  immediately  upon  the  point  formed  by  Cape 
Henlopen,  is  the  reservation,  forty  acres  in  extent,  and  sur- 
rounded by  a  substantial  picket-fence  ten  feet  in  height. 
Within  this  enclosure  is  located  the  quarantine  plant  proper, 
consisting  of  commodious  hospitals  for  contagious  and  non- 
contagious  diseases,  and  barracks  for  the  accommodation  of 
one  thousand  suspects,  fitted  with  bunks  and  provided  with 
bedding  and  a  full  supply  of  clothing  for  both  males  and 
females.  In  connection  with  these  barracks  are  a  large  kitchen, 
fully  equipped  with  steam  cooking-apparatus  of  the  most  im- 
proved description  and  a  commodious  mess-hall.  There  has 
been  also  provided  a  building  containing  a  boiler  for  operating 
the  pumps,  a  bath-house,  and  laundry,  which  latter  is  equipped 
with  appliances  for  washing  all  soiled  clothing  and  for  subject- 
ing them  to  the  boiling  process.  In  this  building  there  is  also 
located  a  steam  disinfecting  chamber  of  the  most  modern  and 
improved  type,  ami  adjoining  this  building  is  a  bath-house 
fitted  with  twenty  shower-  and  two  tub-  baths,  all  provided  with 


496  TEXT-BOOK   OF    HYGIENE. 

hot  and  cold  water.  An  artesian  well  has  been  sunk,  capable 
of  supplying  twenty  thousand  gallons  of  water  per  day,  and 
this  water  is  raised  by  a  powerful  pump  to  elevated  tanks,  and 
from  these  distributed  to  the  barracks,  kitchens,  hospitals, 
laundry,  and  bath-house. 

Latrines  are  provided  and  furaishecf  with  iron  containers 
holding  a  strong  disinfecting  solution,  and  provision  is  made  for 
emptying  these  containers  into  a  sewer,  which,  in  turn,  empties 
into  a  sewer  common  to  the  bath-house  and  laundry,  which 
discharges  into  the  sea.  The  danger  of  soil  contamination  by 
alvine  discharges  is  reduced  to  a  minimum,  and  the  water-supply 
likewise  protected.  Outside  of  the  fence  is  a  large  brick  house, 
which  furnishes  executive  and  administrative  offices  and  quarters 
for  the  medical  officers  on  duty  at  the  station.  In  front  of  the 
executive  building  is  a  lofty  flag-staff,  which  affords  the  means 
for  communicating  by  signals  with  vessels  in  quarantine  and 
arriving  in  the  offing. 

Within  a  few  hundred  yards  of  the  reservation  is  a  long 
iron  pier,  which  affords  ample  facilities  for  the  landing  of  pas- 
sengers. 

Situated  fifty-five  miles  above  the  Breakwater,  and  forty- 
five  miles  from  Philadelphia,  is  the  Reedy  Island  Quaran- 
tine Station,  on  and  near  the  island  of  that  name.  Upon  the 
island  itself  are  situated  the  residence  of  the  medical  officer, 
quarters  for  employes,  and  a  cottage  hospital.  A  boat-house  is 
connected  with  the  island  by  a  gangway.  The  quarantine  plant 
proper  is  located  on  a  pier  situated  on  the  edge  of  the  channel, 
and  in  thirty  feet  of  water.  The  pier  is  two  hundred  feet  in 
length,  and  presents  a  frontage  of  nearly  four  hundred  feet, 
owing  to  the  placing  of  an  ice-break  above  and  below  the 
pier.  This  affords  room  for  the  accommodation  of  the  largest 
vessels,  and  upon  the  wharf  is  situated  the  disinfecting  plant, 
consisting  of  two  steam  chambers ;  a  sulphur-furnace,  fan 
and  engine  for  driving  the  same;  tanks  for  disinfecting  solu- 
tions and  a  pump  and  hose  for  their  distribution  ;  a  fire-pump, 


AIDS   TO   NATIONAL   QUARANTINE.  497 

and  tanks  for  the  storage  of  water  for  fire  and  steaming 
purposes. 

There  are  no  barracks  at  this  station,  it  being  the  plan  that 
the  vessel  shall  receive  quarantine  treatment  at  this  point,  and 
that  the  passengers  shall  undergo  their  detention  in  the  barracks 
at  the  Breakwater  station. 

Another  national  station  which  deserves  special  notice  from 
its  peculiarities  is  the  quarantine  vessel  Jamestown^  which  can 
be  considered  a  floating  quarantine  station.  The  Jamestown 
was  turned  over  to  the  U.  S.  Marine-Hospital  Service  by  the 
Navy  Department  for  quarantine  use.  She  is  one  of  the  old- 
fashioned  sailing-vessels  of  the  navy,  is  very  strongly  and 
solidly  constructed,  and  is  one  hundred  and  sixty-six  feet  long, 
thirty-six  feet  beam,  and  has  a  displacement  of  eight  hundred 
and  eighty-eight  tons.  She  has  been  fitted  for  her  present  use 
by  being  housed  in,  and  there  have  been  placed  on  board  a 
steam  disinfecting  chamber,  a  sulphur-furnace,  tank  for  bichlo- 
ride solution,  and  bath-rooms.  In  addition  to  these,  she  has 
been  fitted  as  a  place  of  detention  for  two  hundred  and  fifty  to 
three  hundred  immigrants,  and  is  in  all  respects  a  complete 
quarantine  station,  and  capable  of  doing  valuable  service  in 
smooth  water. 

AIDS   TO   NATIONAL   QUARANTINE. 

In  aid  of  the  national  quarantines,  sanitary  inspectors  are 
appointed  by  the  Marine-Hospital  Service  at  special  points  of 
danger,  either  in  the  United  States  or  abroad.  Through  the 
State  Department  consular  notification  from  foreign  ports  is 
received  regularly  by  mail,  or,  in  emergency,  by  cable,  and  the 
information  thus  received,  and  that  received  also  from  home 
ports,  is  communicated,  by  the  Marine-Hospital  Bureau,  to  all 
quarantine  authorities  and  others,  by  means  of  a  weekly  publi- 
cation known  as  the  "  Abstract  of  Sanitary  Reports." 

An  important  source  of  information  concerning  the  move- 
ments of  vessels  in  every  portion  of  the  world  is  the  "  Maritime 


498  TEXT-BOOK    OF   HYGIENE. 

Register,"  published  in  New  York.  The  United  States  Col- 
lectors of  Customs  are  efficient  aids,  having-,  by  law,  the  power 
of  search  and  detention  of  vessels,  and  having  exceptional 
knowledge  of  the  sanitary  condition  of  the  shipping  at  their 
respective  ports.  The  Revenue-Cutter  Service,  a  national  coast 
patrol,  gives  frequent  and  efficient  aid ;  the  Light-house  Estab- 
lishment and  Coast  Survey  render  valuable  assistance  in  locating 
and  buoying  the  anchorages,  and  the  Life-Saving  Service,  with 
its  constant  patrol  of  the  coast,  guards  against  the  entry  of  a 
vessel  at  an  unusual  point.  The  surf-men  are  required  to  rake 
together  and  destroy  dunnage  and  other  material  likely  to  be 
infected  that  have  been  thrown  overboard  and  washed  ashore 
from  infected  vessels.  Finally,  the  Marine-Hospital  Service, 
having,  besides  the  quarantines,  the  care  of  the  sick  of  the 
merchant  vessels  of  the  United  States,  with  one  hundred  and 
twenty-six  physicians  stationed  at  the  larger  and  many  of  the 
smaller  ports,  is  ready  at  a  moment's  notice  to  extend  in- 
definitely its  quarantine  service. 

NATIONAL  INSPECTION  OF  ALL  QUARANTINES. 

The  Act  of  Congress  approved  February  15  1893,  while 
contemplating  that  State  and  local  quarantines  shall  not  be  dis- 
turbed in  the  exercise  of  their  functions,  provided  said  quar- 
antines are  administered  in  accordance  with  the  law  and  the 
regulations  made  thereunder,  further  provides  that  the  rules 
and  regulations  of  local  quarantines  shall  be  examined  by  the 
Surgeon-General  of  the  Marine-Hospital  Service,  and  also  that 
such  additional  rules  and  regulations  as  may  be  deemed  neces- 
sary shall  be  made  by  the  Secretary  of  the  Treasury,  and  shall 
be  enforced  by  the  State  or  local  quarantine  authorities.  If  the 
latter  refuse,  or  are  unable  to  enforce  them,  the  law  further 
provides  that  the  President  of  the  United  States  shall  detail  or 
appoint  an  officer  for  this  purpose.  To  carry  out  the  intent  of 
this  law  all  the  quarantines  of  the  United  States,  national,  State, 
and  local,  are  inspected  periodically  by  an  officer  of  the  Marine- 


NATIONAL   INSPECTION   OF   ALL   QUARANTINES.  499 

Hospital  Service.     Following  are  the  instructions  prepared  for 
the  inspecting-  officers: — 

INSTRUCTIONS  TO  MEDICAL  OFFICERS  OF  THE  MARINE-HOSPITAL  SERVICE 
DETAILED  TO  MAKE  INSPECTIONS  OF  STATE  AND  LOCAL  QUARANTINES. 

TREASURY  REGULATIONS. 

*****  **** 

In  the  performance  of  the  duties  imposed  upon  him  by  the  act  of 
February  15,  1893,  the  Supervising  Surgeon-General  of  the  Marine- 
Hospital  Service  shall,  from  time  to  time,  personally  or  through  a  duly- 
detailed  officer  of  the  Marine-Hospital  Service,  inspect  the  mnritime 
quarantines  of  the  United  States,  State  and  local,  as  well  as  national,  for 
the  purpose  of  ascertaining  whether  the  quarantine  regulations  pre- 
scribed by  the  Secretary  of  the  Treasury  have  been,  or  are  being,  com- 
plied with.  The  Supervising  Surgeon-General,  or  the  officer  detailed  by 
him  as  inspector,  shall,  at  his  discretion,  visit  any  incoming  vessel,  or  any 
vessel  detained  in  quarantine,  and  all  portions  of  the  quarantine  estab- 
lishment for  the  above-named  purpose,  and  with  a  view  to  certifying,  if 
need  be,  that  the  regulations  have  been,  or  are  being,  enforced. — J.  G. 
CARLISLE,  Secretary. 

GENERAL   INSTRUCTIONS. 

A.  Your  inspections  will  include  all  ports  within  your  district 
where  vessels  are  allowed  to  enter  and  discharge  cargo,  and  ports  which 
may  be  used  as  ports  of  call. 

B.  A  separate  report  will  be  made  of  each  station  visited. 

C.  Visit   every   part  of  the  quarantine   establishment,  and   take 
necessary  precautions  to  prevent  the  conveyance  of  contagious  or  infec- 
tious disease  through  the  medium  of  your  own  person. 

D.  Visit  the  custom-house  for  the  purpose  of  ascertaining  whether 
the  regulations  with  regard  to  bills  of  health  and  quarantine  certificates 
are  being  observed;   also,  the  immigration    station   for  any  pertinent 
information. 

E.  Reports  of  a  statistical  character  and  descriptive  of  the  quar- 
antine, called  for  herein,  need  be  made  but  once  in  every  six  months, 
namely,  on  the  date  neai'est  the  1st  of  January  and  the  date  nearest  the 
1st  of  July ;  but  any  changes  that  have  been  made  since  the  last  general 
report  should  be  immediately  recorded. 

In  making  your  report  you  will  follow  the  special  instructions  in 
their  order,  referring  to  each  by  number. 


500  TEXT-BOOK   OF   HYGIENE. 

SPECIAL   INSTRUCTIONS. 

1.  Describe  the  quarantine  station,  location,  buildings,  anchorages, 
etc.     Give  limits  of  anchorage  for  non -infected  and  for  infected  vessels ; 
facilities  for  inspection  of  vessels ;  apparatus  for  disinfection  of  vessels 
and  of  baggage ;  facilities  for  removal  and  treatment  of  the  sick,  and  for 
the  removal  and  detention  of  suspects  ;  mail  and  telegraph  facilities,  etc. 

2.  Give  personnel  of  the  station  or  port ;  name  of  the  quarantine 
officer   or   officers ;   post-office   address ;    total  number   of  officers   and 
subordinates,  etc. 

3.  Transmit  copies  of  the  laws  under  which  the  local  quarantine  is 
maintained,  and  copies  of  the  quarantine  regulations ;  also  describe  the 
quarantine  customs  of  the  port  as  they  are  curried  out. 

NOTE. — There  are  sometimes  slight,  but  possibly  important,  variations  from  the 
letter  of  the  local  regulations  in  the  administration  of  quarantine.  Also,  local  regula- 
tions generally  allow  a  wide  latitude  to  the  quarantine  officer,  and  how  this  latitude  is 
used — i.e.,  how  the  quarantine  officer  interprets  the  spirit  of  the  regulations — is  very 
important. 

4.  State  what  quarantine  procedures,  either  under  printed  regula- 
tions or  by  custom,  are  enforced  at  the  port,  in  addition  to  the  require- 
ments of  the  Treasury  Department. 

It  should  also  be  stated  whether  there  is  undue  or  unnecessary 
detention  or  disinfection  of  vessels. 

5.  State  whether  the  inspection  is  maintained  throughout  the  year 
or  for  what  period,  and  what  treatment  of  vessels  is  enforced  during  the 
entire  year. 

NOTE. — Many  ports  on  the  South  Atlantic  coast  (e.g.,  Charleston,  Savannah,  and 
Fernandina)  require  certain  ballasts  to  be  discharged  in  quarantine  without  regard  to 
season. 

6.  Are  vessels  from  other  United  States  ports  inspected  ? 

7.  Describe  quarantine  procedures  in   the   inspection  of  vessels, 
and,  if  infected,  the  treatment.     Give  time  in  quarantine  (a)  between 
arrival  and  commencement  of  disinfection,  (6)  time  occupied  by  disin- 
fection, and  (c)  time  after  completion  of  disinfection  of  vessels  until 
discharge. 

NOTE. — Quick  or  slow  handling  of  a  vessel  is  of  more  importance  commercially 
than  the  question  of  fees.  The  time  lost  is  the  vessel's  heaviest  expense,  generally. 

8.  What  communication  is  held  with  vessels  in  quarantine  (nnd, 
before  quarantine,  by  pilots,  etc.),  and  how  regulated?     Is  there  any 
intercommunication  allowed  among  vessels  in  quarantine? 

9.  State  what  will  be  done  with  a  vessel  infected  with  cholera; 
second,  a  vessel  infected  with  yellow  fever;  third,  a  vessel  infected  with 
small-pox  (said  vessels  carrying  or  not  cany  ing  immigrants),  and  what 


THE    SANITARY   CORDON.  50.' 

conditions  are  regarded  as  giving  evidence  of  the  vessel's  infection  in 
each  case. 

10.  State  whether  records  are  kept,  at  the  station,  of  the  cases  of 
disease  that  have  occurred  during  the  voyage,  on  arrival,  and  during 
detention. 

11.  Transmit  schedule  of  quarantine  fees,  and  give  other  fees  and 
expenses  necessarily  and  usually  attendant  on  quarantine,  as  tonnage, 
ballast,  wharfage  charges,  etc. 

12.  Make  a  statement  showing  the  number  of  vessels  arriving  at 
the   port   during   the   preceding   calendar  year,  by  months,    (a)   from 
foreign  ports;  (6)  from  foreign  ports  in  yellow-fever  latitudes  via  do- 
mestic ports ;  (c)  from  domestic  ports.     Show,  also,  the  character  of  the 
commerce  carried  on  by  the  port, — i.e.,  from  what  countries  chiefly  the 
vessels  come,  and  whether  in  cargo,  ballast,  or  empty. 

13.  State  results  of  your  visit  to  (a)  the  Custom-house;  (6)  the 
Immigration  Bureau. 

14.  State  whether,  in  your  opinion,  the  quarantine  facilities  are 
sufficient  to  care  for  the  shipping  entering  the  port. 

15.  Name  the  quarantine  regulations  of  the  Treasury  Department 
which  are  not  properly  enforced,  and  state  specifically  whether  the  regu- 
lations regarding  inspection  and  disinfection,  and  particularly  the  period 
of  observation  after  disinfection,  of  vessels  are  observed. 

16.  Mention  any  facts  which,  in  your  opinion,  should  be  known  to 
the   Department,  bearing   directly  or  indirectly   upon   the   quarantine 
service,  and   make   such    recommendations   as   seem   proper. — WALTER 
WYMAN,  Supervising  Surgeon- General  M.-H.  S. 

NOTE. — Report  to  be  written  on  legal-cap  paper  (on  one  side  only),  signed,  and 
inclosed  in  this  blank  as  a  cover. 

INLAND  QUARANTINE. 

Under  Inland  Quarantine  will  be  described  The  Sanitary 
Cordon,  Camps  of  Probation,  Railroad  Quarantine,  Disinfection 
Stations,  and  Inspection  Service. 

THE    SANITARY   CORDON. 

This  consists  of  a  line  of  guards,  military  or  civil,  thrown 
around  a  district  or  locality,  either  to  protect  the  same  from  the 
surrounding  country  when  infected,  or  to  protect  the  surround- 
ing country  from  the  infected  district  or  locality.  When  a 
given  locality  is  infected,  and  the  'adjacent  territory  is  regarded 


502  TEXT-BOOK   OF    HYGIENE. 

as  suspicious,  it  may  be  necessary  to  establish  a  double  cordon, 
the  first  one  embracing  the  whole  suspected  territory  at  its 
outer  edge,  the  second  investing  more  closely  the  well-defined 
infected  locality.  After  the  expiration  of  a  sufficient  time  to 
prove  that  the  area  between  the  cordons  is  not  infected,  or  has 
been  cleared  of  infection,  the  first  cordon  may  be  removed. 
Hospitals  and  camps  of  probation  may  be  necessary  adjuncts  to 
the  cordon.  The  most  noted  example  of  the  sanitary  cordon  is 
found  in  the  history  of  the  plague-epidemic  in  Russia  in  1878. 
A  colony  on  the  river  Volga,  called  Wetljankaja,  with  a  popu- 
lation of  1700  inhabitants,  became  infected  with  the  Oriental 
plague,  which  extended  to  the  neighboring  villages.  A  military 
cordon  was  made  to  embrace  all  the  infected  district.  The  in- 
habitants of  the  focus  of  infection,  Wetljankaja,  were  removed, 
property  appraised  for  re-imbursement  by  the  government,  and 
the  village  burned.  An  additional  cordon  was  thrown  around 
Zarizin,  a  neighboring  commercial  city  of  importance  and  ter- 
minus of  the  Russian  railway  system.  The  cordons  were  main- 
tained several  months,  and  the  plague  was  stamped  out.  (See 
Abstract  Sanitary  Reports,  vol.  i  [Bulletin's],  page  78.)  The 
sanitary  cordon  is  the  customary  method  of  preventing  the 
spread  of  epidemic  disease  in  the  eastern  countries. 

In  the  United  States,  when  yellow  fever  prevailed  in  Pen- 
sacola,  in  1882,  to  the  extent  of  2200  cases,  the  navy-yard 
reservation,  whose  boundary-line  is  within  two  miles  of  the 
city  limit,  and  with  a  population  of  about  1500,  was  successfully 
guarded  by  means  of  a  cordon  and  non-intercourse. 

The  following  year,  1883,  the  navy-yard  itself  was  infected, 
and  a  cordon  was  thrown  around  it  to  protect  the  city  of  Pen- 
sacola,  and  "was  maintained  for  a  period  of  sixty  days.  This 
cordon  was  under  the  management  of  the  Surgeon-General  of 
the  Marine-Hospital  Service,  aid  having  been  requested  of  the 
national  government.  The  Collector  of  Customs  of  Pensacola 
was  made  the  agent  to  execute  the  orders  of  the  Marine-Hos- 
pital Bureau,  and  to  the  President  of  the  local  Board  of  Health 


THE    SANITARY   CORDON.  503 

was  intrusted  the  immediate  command  of  the  line  and  guards. 
The  cordon  entirely  surrounded  the  land-houndary  of  the  naval 
reservation.  Its  line  was  tour  miles  in  length,  one  mile  of  it 
through  a  dense  thicket,  and  was  marked  by  blazed  trees  and 
flags.  Forty  men  were  employed  as  guards,  an  equal  number 
being  selected  from  each  of  the  two  political  parties.  Two 
captains  were  appointed,  and  were  obliged  to  supervise  the  line 
night  and  day. 

The  sentinel  posts  were  furnished  with  tents,  and  two  guards 
wore  allotted  to  each  post,  taking  alternate  watches  of  four 
hours  each.  A  detention  or  probation  camp  was  established 
and  placed  in  charge  of  a  physician,  where  persons  wishing  to 
leave  the  reservation  were  obliged  to  pass  a  probationary  period 
of  twenty  days.  Not  more  than  half  a  dozen  persons  were 
received  in  this  camp.  The  government  expended  about 
$20,000  in  these  restrictive  measures,  which  were  entirely  suc- 
cessful. Not  one  person  got  through  the  cordon  line.  The 
success  was  due  largely  to  the  thorough  discipline  maintained 
by  the  Collector  and  the  President  of  the  Board  of  Health. 

Yellow-Fever  Cordon  in  Texas. — In  1882,  yellow  fever 
prevailing  in  Mexico,  along  the  Rio  Grande,  and  in  Browns- 
ville, Texas,  a  sanitary  cordon  was  established  by  the  Surgeon- 
General  of  the  Marine-Hospital  Service,  on  request  of  the 
Governor  of  the  State,  extending  along  the  line  of  the  railroad 
from  Corpus  Christi,  on  the  Gulf  of  Mexico,  inland  to  Laredo, 
on  the  Rio  Grande.  This  line  was  one  hundred  and  eighty 
miles  northeast  of  Brownsville,  the  triangular  territory  thus 
hemmed  in  by  the  cordon  on  one  side,  the  Rio  Grande  on 
another,  and  the  Gulf  on  the  third,  being  all  suspected  terri- 
tory, although  the  fever  prevailed  in  only  one  corner  of  it, — 
vi/.,  in  Brownsville.  All  persons  were  detained  at  least  ten 
days  at  the  cordon  before  being  allowed  to  pass  northward, — a 
period  of  probation  to  insure  that  no  one  having  the  disease 
should  carry  it  farther  north.  As  soon  as  practicable  another 
cordon  was  established  much  nearer  to  Brownsville,  only  thirty 


504  TEXT-BOOK    OF   HYGIENE. 

miles  from  it,  the  line  extending  from  the  mouth  of  the  Sol 
Colorado,  on  the  Gulf  of  Mexico,  to  Santa  Maria,  on  the  llio 
Grande.  After  a  time  sufficient  to  prove  that  no  more  fever 
prevailed  between  the  two  cordons,  the  first  one  was  removed. 
Within  the,  second  line,  where  the  fever  prevailed,  chiefly  in 
Brownsville,  a  hospital  was  established  and  dispensaries  opened 
for  the  gratuitous  treatment  of  all  applicants. 

Upon  the  Mexican  side  of  the  Rio  Grande  the  fever  con- 
tinued to  spread  northwardly,  and,  in  order  to  oppose  it,  still 
another  cordon  had  to  be  established  on  the  American  side  of 
the  river,  extending  from  Santa  Maria  on  the  south  to  Laredo 
on  the  north,  a  distance  of  five  hundred  miles.  Three  hundred 
guards,  well  mounted  (Texan  cow-boys),  were  employed  in  this 
cordon,  and,  while  the  disease  was  being  stamped  out  in 
Brownsville,  any  further  importation  from  Mexico  was  thus 
prevented.  In  Mexico  the  fever  continued  to  spread  until  the 
authorities  finally  adopted  measured  similar  to  the  above. 

The  epidemic  of  yellow  fever  in  Brunswick,  Ga.,  in  1893, 
.gave  rise  to  the  necessity  of  establishing  a  sanitary  cordon  to 
protect  the  surrounding  country  from  the  danger  incident  to  the 
panic-engendered  flight  of  the  inhabitants  of  that  town.  On 
account  of  the  peculiar  situation  of  Brunswick  the  difficulties 
to  be  met  were  very  great.  Not  only  were  numerous  roads  to 
be  guarded,  but  three  water-passages  from  the  city  into  the 
surrounding  country  had  also  to  be  watched.  The  cordon, 
therefore,  partook  of  the  nature  of  both  a  land  and  water 
patrol,  and  the  difficulties  were  successfully  overcome,  and 
no  well-authenticated  instances  of  escape  through  the  lines 
were  established. 

Much  violent  language  has  been  used  concerning  the 
hardships  imposed  by  the  sanitary  cordon,  but  in  the  presence 
of  an  epidemic  the  authorities  who  are  responsible  need  to  pay 
more  heed  to  the  efficiency  of  the  cordon  than  to  individual 
complaints.  It  should  be  borne  in  mind  that  the  sanitary 
cordon  is  not  intended  to  bottle  up  all  the  people  who  are 


CAMPS   OF   PROBATION.  505 

caught  within  an  infected  district.  On  the  contrary,  it  is 
intended  as  a  means  of  exit  to  those  who  will  not  carry  with 
them  contagious  disease  to  the  people  beyond. 

The  cordon,  then,  imposes  simply  a  period  of  detention 
corresponding  to  the  incubative  period  of  the  prevailing  disease. 
Ample  preparation  must  be  made  for  housing  and  feeding,  in 
camps  or  other  quarters,  persons  awaiting  the  expiration  of  the 
detention  period ;  and  hospitals  must  be  provided  for  the  treat- 
ment of  those  who  develop  sickness.  Provision  must  also  be 
made  for  the  disinfection  of  suspected  baggage. 

CAMPS   OF   PROBATION. 

Camps  of  probation  or  detention  should  be  established  with 
all  the  precision  of  arrangement  and  regard  for  site,  water,  and 
drainage  that  pertain  to  a  military  camp.  Every  effort  should 
be  made  to  make  the  camp  as  comfortable  and  cheerful  as  pos- 
sible, and  to  this  latter  end  amusements  and  entertainments 
such  as  might  be  suggested  by  the  campers  themselves  should 
be  encouraged.  Every  necessity  in  the  matter  of  food,  bedding, 
and  the  ordinary  comforts  of  life  should  be  anticipated,  to  pre- 
vent any  just  cause  of  complaint.  Such  a  natural  division  of 
the  inhabitants  should  be  made  as  seems  desirable  at  the  time, 
those  of  equal  intelligence  and  refinement  naturally  seeking 
each  other's  company.  The  greatest  concern  is  to  prevent  the 
camp  itself  from  becoming  infected.  To  this  end  no  baggage 
should  be  allowed  within  the  camp-boundary  without  previous 
disinfection ;  and  every  refugee  should  be  examined  by  a  phy- 
sician before  being  admitted  to  the  camp.  No  one  should  be 
received  who  does  not  intend  to  proceed  to  an  uninfected  locality 
after  his  probation.  In  other  words,  a  camp  of  probation  should 
not  be  used  as  one  of  refuge. 

The  camp  must  be  surrounded  by  guards  to  prevent  egress 
or  ingress,  excepting  through  the  established  portal.  At  least 
twice  or  three  times  in  the  twenty-four  hours  all  refugees  should 
be  inspected  in  their  quarters,  and  any  case  of  sickness  at  once 


506  TEXT-BOOK   OF   HYGIENE. 

be  isolated  and  watched  until  the  diagnosis  is  certain.  If  the 
case  is  one  of  the  prevailing  disease,  the  patient  must  be  re- 
moved immediately  to  the  hospital,  which  should  be  at  a  safe 
distance,  half  a  mile  or  more,  from  the  camp.  Before  leaving 
the  camp,  each  refugee's  clothing  should  be  fumigated,  and  he 
should  be  given  a  certificate  that  he  has  passed  the  required 
period  of  probation.  A  clear  distinction  must  be  made  between 
camps  of  probation  and  camps  of  refuge.  Camps  of  refuge  are 
simply  residence  camps  established  to  receive  the  population  of 
an  infected  community  when  it  has  been  determined  to  depopu- 
late the  infected  district. 

Depopulation  of  a  house,  a  block,  a  district,  or  a  whole 
city,  if  possible,  the  people  moving  into  camps,  is  now  recog- 
nized as  a  valuable  means  of  controlling  an  epidemic ;  and 
there  may  be  either  camps  of  probation  or  simply  camps  of 
refuge,  or  both,  according  to  the  requirements  of  the  situation. 
Camps  of  refuge,  in  connection  with  depopulation,  were  sug- 
gested by  the  late  Surgeon-General  Wood  worth,  in  1878,  and 
the  measure  was  practically  carried  out  at  Memphis,  in  1879, 
by  the  establishment  of  Camp  Mitchell.  "  But  the  establish- 
ment of  a  camp  to  which  persons  from  infected  points  could  go, 
be  kept  under  observation  a  sufficient  length  of  time  to  demon- 
strate they  were  not  infected,  have  their  baggage  disinfected, 
and  be  given  'free  pratique,'  is  apparently  a  new  departure  in 
inland  quarantine." 

Camp  Perry,  Fla. — Such  was  Camp  Perry,  Florida,  de- 
scribed by  the  surgeon  in  charge,  W.  H.  H.  Hutton,  in  the 
Marine-Hospital  Service  Report  for  1889.  The  site  was  admira- 
bly chosen  by  Passed  Assistant  Surgeon  John  Guiteras,  upon  a 
bluff  on  the  south  side  of  St.  Mary's  River,  the  dividing  line 
between  Florida  and  Georgia,  about  forty  miles  north  of  Jack- 
sonville, Fla.,  which  city  was  in  the  throes  of  a  yellow-fever 
epidemic.  The  camp  was  opened  August  20,  1888.  It  con- 
sisted, in  its  completed  stage,  first,  of  50  wooden  cottages  built 
elsewhere  and  transported  on  cars.  Their  dimensions  were  12 


.      CAMPS   OF   PROBATION.  507 

feet  by  10,  and  10  feet  in  height,  constructed  of  plain  lumber, 
with  cracks  battened,  and  windows  on  each  side  with  swinging 

o     o 

shutters.  Each  held  four  cots,  chairs,  and  toilet-stand,  while 
unused  clothing-  was  neatly  arranged  on  the  rafters  above. 
Besides  the  50  cottages  there  were  a  quartermaster  and  guard- 
house, commissary  building,  dining-room  and  kitchen,  and 
laundry,  built  of  rough  lumber ;  2  Ducker  portable  barracks, 
each  18  by.  35  feet,  provided  with  12  beds  each,  and  350 
tents,  used  principally  by  the  single  men,  the  employes  and 
guards,  and  the  colored  refugees.  So  far  as  known,  this  is 
the  first  camp  of  the  kind  ever  established ;  at  least,  in  the 
United  States.  The  cottages  were  arranged  in  a  quadrangle 
around  a  parade-ground  two  acres  in  extent,  and  the  tents  were 
arranged  in  streets  and  alleys  in  the  rear  of  the  cottages.  The 
accommodations  were  sufficient  for  600  people,  and  extra  tents 
were  on  hand  so  that,  if  required,  1000  persons  could  have  been 
provided  for,  or  3000  per  month,  allowing  for  only  ten  days' 
detention  of  each  person.  Two  hundred  hospital  tents  will 
accommodate  1200  people  comfortably,  according  to  Surgeon 
Hutton,  who  states  that  the  small  A-tents  are  unsuited  for 
women  and  children,  but  will  answer  for  men  or  boys.  Wire- 
mattress  cots  should  be  provided.  The  marine-hospital  officer 
at  Savannah  Ga.,  was  the  purchasing  agent  for  the  camp,  and 
promptly  forwarded  all  subsistence  supplies  on  requisition  by 
mail  or  telegraph. 

Discipline  of  the  Camp. — On  arrival  of  a  train,  each  pas- 
senger was  personally  examined  by  a  physician,  his  health- 
certificate  scrutinized,  and  he  was  made  to  await  the  examination 
of  others.  Hand-bags,  clothing,  and  loose  wearing-apparel 
were  left  in  the  baggage-car  for  disinfection.  The  refugees  were 
then  marched  to  the  quartermaster's  room  for  registration  and 
assignment  to  quarters.  On  first  arrival  they  were  placed  in  the 
southern  part  of  the  camp,  and  in  two  days,  there  being  no 
sickness,  were  moved  forward  several  cabins,  and  this  progres- 
sion was  repeated  until  the  time  for  discharge. 


508  TEXT-BOOK   OF   HYGIENE. 

Twelve  guards  were  employed,  under  the  command  of  a 
captain,  and  were  divided  into  squads  of  four  each.  The 
schedule  was  so  arranged  that  each  guard  was  on  duty  two 
hours  and  off  duty  four. 

A  bugler  announced  the  several  calls,  as  follow : — 

5.30  A.M.,  ....  Reveille. 

6.00  A.M.,  ....  Breakfast,  employe's. 

7.00  A.M.,  ....  Breakfast,  guests. 

9.00  A.M.,  ....  Surgeon's  call  and  inspection. 

12.00     M.,  .         .         .         .  Dinner,  employe's. 

1.20  P.M.,  ....  Dinner,  guests. 

4.30  P.M.,  ....  Surgeon's  call  and  inspection. 

5.30  P.M.,  ....  Supper,  guests. 

6.00  P.M.,  ....  Supper,  employe's. 

6.30  P.M.,  ....  Retreat  and  change  of  guard. 

9.00  P.M.,  ....  Retiring  taps. 

The  yellow-fever  hospital  camp,  under  the  special  charge 
of  Dr.  Faget,  was  located  one-half  mile  from  the  probation 
camp.  It  consisted  of  2  frame  buildings,  2  hospital  and  12 
smaller  tents,  arranged  in  a  double-crescent  shape,  the  avenue 
in  the  middle  presenting  an  attractive  appearance. 

Of  the  12  small  tents,  4  were  for  nurses,  3  for  employes, 
2  for  convalescents,  and  1  each  for  drug-store,  storage-  and 
dead-  house.  One  of  the  hospital  tents  was  used  as  a  dining- 
room  for  employes,  convalescents,  and  parents  of  the  sick. 

The  hospital  was  established  September  3,  1888,  and  be- 
tween that  date  and  November  24th  35  cases  of  yellow  fever 
were  admitted  and  treated,  3  died,  and  32  were  discharged. 
Twelve  hundred  and  eleven  refugees  were  received  into  Camp 
Perry,  nearly  all  of  whom  were  from  the  infected  district  of 
Jacksonville. 

Thirty-five  cases  of  yellow  fever  were  caught  by  the  ten 
days'  detention,  but  no  case  of  fever  was  contracted  at  the  camp, 
and  of  the  1208  refugees  who  passed  the  required  detention  and 
proceeded  to  different  parts  of  the  country,  so  far  as  known,  not 
one  subsequently  developed  or  carried  the  disease  elsewhere. 


CAMPS   OF   PROBATION.  509 

The  general  plan  of  the  preventive  measures  adopted  during  this 
epidemic  will  be  described  under  Railroad  Quarantine. 

Detention  Camp,  Waynesville,  Ga.— The  epidemic  of 
yellow  fever  in  Brunswick,  Ga.,  in  1893,  caused  the  establish- 
ment of  another  camp  of  probation  near  Waynesville,  Ga. 
Following  is  the  report  of  the  medical  officer  in  command : 

SIB  :  I  have  the  honor  to  present  the  following  report  of  the  opera- 
tions of  the  detention  camp  near  Waynesville,  Ga. 

The  camp  was  officially  opened  for  the  reception  of  refugees  from 
Brunswick,  Ga.,  on  the  18th  of  September,  1893,  and  closed  by  the  order 
of  Surgeon  R.  D.  Murray,  Marine-Hospital  Service,  permitting  the 
return  of  all  refugees  to  their  homes  in  Brunswick,  November  30,  1893. 

Four  hundred  and  thirty-one  persons  availed  themselves  of  the 
privileges  of  the  camp,  of  whom  about  two  hundred  and  twenty-five 
were  white  and  the  remainder  black  and  colored. 

The  site  of  the  camp  was  selected  by  Surgeon  W.  H.  H.  Hutton, 
and  was  twenty-three  miles  west  of  Brunswick,  immediately  upon  and 
on  the  south  side  of  the  Brunswick  and  Western  Railway,  and  upon  an 
eminence  about  twenty-five  feet  above  the  level  of  the  surrounding  coun- 
try, which  is  generally  swampy,  and  within  a  mile  of  the  margin  of 
what  is  locally  known  as  the  Buffalo  Swamp.  As  is  usual  in  this  sec- 
tion, the  elevation  was  covered  with  a  dense  growth  of  yellow-pine, 
scrub-oak,  and  black-gum  trees.  The  soil  was  a  gray,  sandy  loam,  over- 
lying a  stratum  of  yellow  clay,  and  the  natural  drainage  of  the  site  in  all ' 
directions  was  good. 

On  my  arrival  I  found  that,  under  the  direction  of  Surgeon  Hut- 
ton,  an  area  of  two  hundred  feet  had  been  cleared  of  trees  and  under- 
growth, and  at  the  four  corners  of  this  square  rough  but  substantial 
buildings  had  been  erected,  which  were  used,  respectively,  as  kitchen, 
white  and  colored  dining-rooms,  guard-room,  quartermaster's  store-room, 
executive  office,  telegraph  office,  and  commissary.  A  depot  and  baggage- 
room  were  provided  at  the  railway.  Along  the  lines  connecting  these 
buildings,  at  intervals  of  twelve  feet,  were  placed  wall-tents,  twelve  by 
fourteen  feet,  with  flies,  and  subsequently  further  rows  of  tents  were 
pitched  behind  these  and  opening  on  streets  fourteen  feet  wide.  All 
tents  were  provided  with  substantial  floors  raised  six  inches  above  the 
ground,  and  the  following  equipment  was  provided:  For  each  inmate, 
one  spring,  wire-bottomed  cot,  one  cotton  mattress,  one  hair  pillow,  two 
sheets,  one  pillow-case,  and,  for  each  tent,  two  tin  wash-bowls,  two  tin 
cups,  and  two  wooden  chairs.  Remarkable  ingenuity  was  displayed  by  the 


510  TEXT-BOOK   OF   HYGIENE. 

inmates  in  the  construction  of  articles  of  furniture  from  packing-cases, 
waste  lumber,  etc.  The  tents  proved  of  good  quality  in  service,  and 
quite  comfortable  in  all  weather.  It  is  suggested,  however,  that  any 
future  tents  be  constructed  with  a  wall  two  feet  higher  and  of  one  foot 
greater  pitch.  A  hospital  establishment  of  two  buildings  was  provided 
at  a  distance  of  one-half  mile  from  the  camp.  A  lofty  pine-tree  was 
fitted  with  a  topmast,  and  served  as  a  staff  for  the  display  of  the 
national  colors  from  sunrise  to  sunset  each  day. 

The  following  routine  was  observed,  the  calls  being  given  by  the 
bugle : — 

5.30  A.M.,    .         .         .     Reveille  and  attendants'  breakfast. 

6.00  A.M.,    .         .         .     Breakfast. 

8.00  A.M.,    .         .         .     Sick  call. 
12.00     M.,    .         .         .     Dinner. 

4.00  P.M.,    .         .         .     Sick  call. 

5.00  P.M.,    .         .         .     Supper. 

Sunset,       .         .         .     Retreat  and  call  to  quarters. 

9.00  P.M.,    .         .         .     Tattoo. 

9.15  P.M.,    .         .         .     Taps  (extinguish  lights). 
The  meals  were  substantial,  abundant,  and  as  varied  as  possible. 
In  all  cases  women  and  children  were  served  at  the  first  table,  and  the 
races  were  served  in  separate  dining-rooms. 

The  following  -rules  were  announced,  and  seemed  to  work  well  in 
practice : — 

1.  At  reveille  all  inmates  will  rise  and  prepare  for  breakfast. 

2.  All  quarters  must  be   clean,  floors   swept,  and  beds  made  up 
before  first  sick  call. 

3.  Meals  will  be  served  in  the  dining-rooms  only,  and  at  stated 
hours,  arid  no  meals  shall  be  carried  from  the  dining-rooms  to  any  quar- 
ters, except  upon  the  written  order  of  the  medical  officer,  renewed  from 
day  to  day. 

4.  At  sick  calls  all  inmates  will  repair  to  their  quarters,  and  be 
there  visited  and  inspected  by  the  medical  officer,  who  will  prescribe  or 
advise  as  he  may  deem  best. 

5.  All  suspicious  cases  of  disease  will  be  isolated  at  once,  and  until 
such  time  as  the  nature  of  the  same  may  be  determined. 

6.  All  cases  of  infectious  disease  will  be  treated  only  in  the  hos- 
pital provided  for  the  purpose. 

7.  No  baggage  from  infected  localities  shall  be  brought  into  camp 
until  disinfected  by  such  process  as  may  be  directed,  and  only  such 
wearing-apparel  as  may  be  deemed  absolutely  necessary  will  be  brought 
into  camp  alter  the  disinfecting  process. 


CAMPS   OF   PROBATION.  511 

8.  All  wearing-apparel  shall  be  a  second  time  disinfected  before 
discharge  from  camp. 

9.  Any  person  taken  ill  between  two  sick  calls  shall  at  once  notify 
the  nearest  guard,  who  will,  in  turn,  at  once  notify  the  medical  officer. 

10.  Guards  are  enjoined  by  their  vigilance  to  prevent  the  commis- 
sion of  any  nuisance  near  any  quarters;  should  such  nuisance  be  discov- 
ered, the  inmates  of  the  nearest  quarters  will  be  required  to  police  the 
same  under  the  supervision  of  the  guard,  who  will  make  report  of  the 
same. 

11.  Inmates  will  confine  themselves  to  the  inner  lines  of  the  camp 
after  retreat  (sunset)  call. 

12.  While  innocent  enjoyment  will  be  encouraged,  the  strictest  pro- 
priety of  conduct  will  be  demanded  and  enforced. 

The  discipline  of  the  camp  was,  in  the  main,  good  throughout.  But 
two  confinements  for  misbehavior  were  required  during  the  entire  dura- 
tion of  the  camp. 

All  baggage  was  submitted  to  steam  disinfection  upon  arrival  at 
and  departure  from  camp.  The  apparatus  used  was  devised  by  Surgeou 
H.  R.  Carter,  Marine-Hospital  Service,  and  was  constructed  in  a  baggage- 
car,  the  steam  being  supplied  by  a  locomotive. 

In  addition  to  other  duties,  nearly  sixteen  hundred  cars,  boxes,  and 
flats  were  disinfected  for  the  B.  and  W.  Railway,  sulphur  fumigation 
being  used  for  the  boxes  and  drenching  with  acid  solution  of  bichloride 
of  mercury  (1  to  800)  for  flat  cars.  This  disinfection  of  cars  enabled 
the  traffic  into  Brunswick  to  be  carried  on  with  a  minimum  of  delay  and 
hardship. 

Two  cases  of  yellow  fever  occurred  among  the  inmates  of  the  camp, 
one  resulting  in  recovery,  one  in  death.  Both  cases  occurred  in  the 
persons  of  sailors  who  had  arrived  in  Brunswick  on  vessels  trading  there, 
mid  both  would  seem  to  show  a  period  of  incubation  of  at  least  five  days, 
thus  justifying  our  detention  of  ten  days. 

Recommendations. — Experience  having  shown  certain  things  to  be 
desirable,  I  would  respectfully  recommend  : — 

1st.  That  a  disinfecting  car  be  built  and  kept  equipped  for  service 
in  epidemics. 

The  nine-foot  chamber  built  by  the  Kensington  Engine-Works  of 
Philadelphia  for  this  Service  might  be  easily  erected  on  a  specially-con- 
structed car,  and  would  prove  more  efficient  in  practice  than  extempo- 
rized apparatus.  Another  ear  might  be  fitted  with  apparatus  for  sulphur 
and  bichloride-of-mercury  disinfection,  and  a  tank-car  similar  to  those 
used  for  the  transportation  of  petroleum  would  complete  a  train  that 


512  TEXT-BOOK   OF   HYGIENE. 

would  be  always  ready  for   emergencies  in  any  part   of  the  country. 
Steam  could  be  supplied  by  a  locomotive  hired  for  the  purpose. 

2d.  That  while  experience  has  demonstrated  the  usefulness  of  tents, 
those  provided  in  the  future  should  be  higher  in  the  pitch  and  the  wall, 
and  that  some  provision  be  made  for  heating  in  severe  weather.  It  is  a 
question  in  my  mind  whether  the  Sibley  conical  tent,  made  with  a  higher 
wall,  would  not  be  preferable,  on  this  account,  to  the  square  tent. 

3d.  That  in  future  epidemics  of  yellow  fever  apparatus  be  pro- 
vided for  observations  into  temperature,  temperature  maximum  and  min- 
imum, barometric  pressure,  dew-point,  direction  and  velocity  of  the  wind, 
precipitation,  and  ozone. 

4th.  That  apparatus,  instruments,  and  reagents  be  provided  for  in- 
vestigation into  the  etiology  of  yellow  fever  in  future  epidemics. 

Yery  respectfully, 
(Signed)  H.  D.  GEDDINGS, 

P.  A.  Surgeon  M.-H.  S. 

To  the  Supervising  Surgeon-General  Marine-Hospital  Service. 

RAILROAD    QUARANTINE    AND    INSPECTION    SERVICE. 

Railroad  quarantine  and  inspection  service  may  be  described 
by  a  brief  account  of  the  actual  measures  of  this  nature  made 
use  of  during  the  yellow-fever  epidemic  in  Florida,  in  1888,  of 
which  Camp  Perry,  just  described,  was  an  important  adjunct. 
(For  details,  see  annual  reports  Marine-Hospital  Service,  1888 
and  1889.) 

The  Governor  of  Florida  made  application  to  the  national 
authorities,  July  16th,  for  aid,  and  it  was  determined  to  prevent 
further  spread  of  the  disease  by  disinfecting  all  baggage  from 
infected  localities  before  permitting  its  transportation  into  other 
States,  and  by  enforcing,  upon  all  persons  from  infected  localities 
seeking  to  leave  the  State,  a  probationary  detention  of  ten  days. 

Accordingly,  disinfection  stations  were  established  at  two 
points,  through  which  all  persons  leaving  Florida  by  rail  were 
obliged  to  pass.  One  of  these  was  at  Live  Oak,  in  North- 
western Florida ;  the  other  at  Way  Cross,  Georgia,  near  the 
boundary-line  of  Northeastern  Florida.  The  only  other  means 
of  egress  from  the  State  was  from  the  sea-ports ;  but  healthy 
sea-ports  maintained  a  vigorous  quarantine  against  people  from 


RAILROAD    QUARANTINE    AND    INSPECTION    SERVICE.  513 

the  infected  districts,  and  infected  sea-ports  were  not  visited  by 
the  steam-ship  lines,  because  their  vessels  would  thereby  be  made 
liable  to  quarantine  detention  at  other  ports.  The  fumigation 
of  baggage  at  Live  Oak  and  Way  Cross  was  accomplished  by 
means  of  box-cars  specially  prepared,  and  subsequently  in 
warehouses,  the  agent  being  sulphur  dioxide. 

Regarding  persons,  the  inspectors,  properly  uniformed  and 
wearing  official  shields,  boarded  the  trains  when  the  latter  arrived 
at  the  inspection  stations,  and  demanded  of  each  passenger  a 
certificate,  showing  where  he  had  been  during  the  previous  ten 
days,  which  certificate  was  considered  valid  only  when  it  bore 
the  seal  or  signature  of  some  officer  of  health,  or  recognized 
municipal  authority.  The  inspectors  themselves  were  kept 
informed  regarding  all  infected  or  suspected  localities,  and  a 
person  coming  from  such  locality  was  either  made  to  return  to 
it  or  given  the  option  of  going  to  the  camp  of  probation,  there 
to  spend  the  ten  days'  period  of  probation  before  being  allowed 
to  enter  other  States. 

This  was  Camp  Perry,  previously  described,  located  38 
miles  south  of  the  Way  Cross  Station,  and  40  miles  north  of 
Jacksonville,  where  the  epidemic  prevailed  chiefly.  All  egress 
from  Jacksonville  was,  perforce,  through  Camp  Perry  and  its  ten 
days'  probation. 

This  camp  was  a  means  of  protecting  not  only  other  States, 
but  the  uninfected  portions  of  Florida  itself,  more  particularly 
Southern  Florida,  whose  health  authorities  refused  to  admit 
within  their  limits  the  refugees  from  the  infected  districts  unless 
they  had  passed  the  period  of  probation  at  Camp  Perry.  To 
assist  in  this  protection  to  Southern  Florida,  no  person  was 
allowed  to  board  a  south-bound  train  between  Way  Cross, 
on  the  north,  and  Orange  Park,  a  station  20  miles  south  of 
Jacksonville. 

Moreover,  through  south-bound  trains  were  boarded  at 
Way  Cross,  and  all  passengers  compelled  to  furnish  evidence  of 
coming  from  healthful  localities.  The  evidence  consisted  of 

33 


514  TEXT-BOOK   OF   HYGIENE. 

certificates  from  local  authorities,  baggage-checks,  or  railroad- 
tickets  showing  they  were  purchased  in  the  North,  and  in  some 
instances  letters  showing  by  the  superscription  and  stamps 
where  the  person  had  been. 

No  train,  excepting  the  special  government  train,  was 
allowed  to  stop  at  Camp  Perry.  A  government  train  also 
carried  those  who  had  passed  the  period  of  probation  from 
Camp  Perry  to  a  point  3|  miles  distant,  Folkstone,  where  they 
were  transferred  to  a  regular  train  running  as  far  north  as  Way 
Cross,  Ga.,  where  another  transfer  had  to  be  made  to  a  regular 
north-bound  train.  No  Florida  passenger-car  was  allowed  to 
go  north,  and  more  than  1000  baggage-  and  freight-  cars  were 
disinfected  by  government  officers  before  being  allowed  to  leave 
the  State. 

Train-Inspection  Service  during  the  Brunswick  Epidemic. 
— During  the  Brunswick  epidemic  the  following  regulations  for 
the  inspection  of  trains  were  promulgated  and  enforced : — 

Inspectors  will  allow  none  to  board  a  train,  unless  with  a  certificate, 
between  Way  Cross  and  Savannah. 

If  certificate  can  be  examined  before  boarding,  without  detention 
to  train,  it  must  be  done,  and  those  which  are  unsatisfactory  will  not  be 
allowed  to  board. 

After  boarding,  the  certificate  and  the  person  must  be  carefully  ex- 
amined and  the  inspector  assure  himself  that  the  passenger  is  not  recently 
from  Jesup.  or  any  infected  locality. 

If  the  passenger  is  known  to  be  a  recent  resident  of  Jesup  or  any 
infected  locality,  or  to  have  been  in  such  place  during  the  past  two  (2) 
weeks,  he  will  not  be  allowed  to  board,  even  if  he  has  a  certificate. 

If,  after  boarding,  either  the  certificate  or  the  examination  of  pas- 
sengers is  not  satisfactory,  the  passenger  will  be  turned  over  to  the  city 
authorities  at  Way  Cross  or  Savannah,  or  at  the  place  where  he  desires 
to  stop.  If  between  these  places,  the  facts  to  be  noted  and  reported. 

A  record  will  be  kept  of  the  names  of  all  passengers  inspected,  name 
of  signer  of  certificate  and  his  rank,  date  of  inspection,  date  of  certificate, 
and  place  of  boarding  train ;  and  where  passenger  is  bound  and  what  dis- 
position is  made  of  him,  whether  passed  or  turned  over  to  local  authori- 
ties ;  also  any  other  facts  worth  notice. 

Inspectors  will  aid  local  quarantine  authorities  in  any  way  in  their 


RAILROAD    QUARANTINE    AND    INSPECTION    SERVICE.          515 

power  consistent  with  their  duties,  and  give  them  any  information, 
obeying  all  local  quarantine  regulations.  Inspectors  report  to  Surgeon 
Carter,  United  States  Marine-Hospital  Service,  or  A.  P.  English,  M.D. 

Rules  Adopted  by  Montgomery  Conference  for  Railroad 
Quarantine. — The  following  are  the  rules  for  railroad  quaran- 
tine adopted  by  the  Quarantine  Conference  held  in  Montgomery, 
Ala.,  March  5  to  7,  1889  :— 

1.  Quarantine  should  not  be  made  against  any  place  until  it  is 
officially  known  that  yellow  fever  or  other  infectious  or  contagious  dis- 
ease exists  at  such  place. 

2.  Only  competent  physicians  should  be  put  in  charge  of  quaran- 
tine stations,  and  only  thoroughly-qualified  persons  should  be  employed 
as  inspectors  on  railway-trains. 

3.  Quarantine  stations  located  on  railroads  should  be  established 
at  convenient  points,  on  one  or  both  sides  of  a  town  or  station,  as  may 
be  deemed  necessary. 

4.  If  an  epidemic  of  yellow  fever  or  other  infectious  or  contagious 
disease  exist  at  a  town  or  station,  trains  carrying  passengers  or  freight 
should  be  required  to  pass  through  the  limits  of  such  towns  or  stations 
at  a  speed  of  not  less  than  ten  miles  per  hour,  without  stopping  at  such 
towns  or  stations,  but  should  stop  at  the  quarantine  station. 

5.  Passengers  to  or  from  such  infected  point  should  only  be  received 
or  delivered  at  the  quarantine   station,  under  the  supervision  of  the 
quarantine  officer  in  Charge  of  the  station. 

6.  Railway-tickets  may  be  sold  to  persons  leaving  an  infected  place 
to  any  point  willing  to  receive  them. 

7.  All  baggage  from  any  infected   point  should  be  properly  disin- 
fected. 

8.  As  far  as  practicable,  the   same  rules   proposed  for  railroads 
should  be  applied  to  vessels  of  every  kind,  stage-coaches,  or  other  means 
of  travel. 

9.  The  passage  of  railroad-trains  through  any  point  on  the  line  of 
road,  whether  infected  or  not,  should  not  be  prohibited  by  any  quaran- 
tine regulations.     The  conductors  of  passenger-trains  should  close  the 
windows  and  ventilators  and  lock  the  doors  of  cars  passing  through  any 
place  where  a  train  is  not  permitted  to  stop. 

10.  All  freight  to  any  infected  place  should  be  delivered  either  at 
the  quarantine  station  or  the  nearest  railway-station  to  such  infected 
point  where  it  can  be  properly  cared  for. 


516  TEXT-BOOK    OF    HYGIENE. 

11.  All   mail-matter   from  any  infected  place  should  be  properly 
disinfected  by  the  United  States  Government ;  and  mail-matter  intended 
for  infected  points  should  be  put  off  the  trains  at  the  quarantine  stations. 
The  United  States  Government  should  instruct  postmasters  to  receive 
and  deliver  mails  at  such  quarantine  stations. 

12.  Railroads  and  express  companies  may  receive  for  transporta- 
tion from  any  infected  place,  during  the  time  such  infection  exists,  any 
merchandise  or  traffic  consigned  to  places  willing  to  receive  it. 

13.  State  authorities  should  employ  competent  persons  on  passen- 
ger-trains as  inspectors  of  passengers,  baggage,  and  express  matter,  as 
additional  precaution;  but  the  fact  of  inspectors  being  on  such. trains 
should   not   relieve   trains  carrying    passengers   or   express '  matter   or 
baggage  from  stopping  at  quarantine  stations  for  such  inspection  as  the 
officer  in  charge  may  determine  to  be  necessary. 

14.  It  is  recommended  that  all  quarantines,  as  far  as  practicable, 
should   be   uniform  in  their    requirements   and   operations,  which  will 
greatly  contribute  to  the  prevention  of  panics,  and  tend  to  allay  un- 
necessary excitement  and  fear  on  the  part  of  the  people. 

15.  The  form  of  health  certificate  adopted  by  the  Quarantine  Con- 
vention  held   at   Montgomery,  March  5,  1889,  should  be  prepared  for 
health  officers  to  issue  to  such  persons  as  may  be  found  entitled  to  re- 
ceive the  same.     A  copy  of  this  certificate  should  be  printed  with  these 
rules,  and  conspicuously  posted  at  railway-stations. 

16.  It  is  the  desire  and  intention  of  health  authorities,  as  far  as 
practicable,  to  throw  every  safeguard  around  the  public  health  of  all 
localities.     Municipal,  county,   and   State   authorities   are   expected  to 
co-operate  in  every  possible  way  with  health  officers  located  in  towns, 
villages,  and  cities,  and  in  charge  of  quarantine  stations,  to  enable  them 
to  prevent  the  introduction  or  spread  of  yellow  fever  or  other  infectious 
or  contagious  diseases. 

It  was  also  resolved  by  this  conference  that  the  best  form 
of  disinfectant  for  personal  baggage  is  moist  heat. 

The  methods  of  railroad  quarantine  may  also  be  studied 
in  a  review  of  the  action  taken  to  prevent  the  introduction  of 
small-pox  into  the  United  States  from  Canada,  where  it  prevailed 
extensively  in  the  fall  and  wiflter  of  1885,  and  January  and 
February,  1886. 

The  following  regulations  were  issued  by  the  Surgeon- 
General  of  the  Marine-Hospital  Service,  October  10,  1885 : — 


RAILROAD   QUARANTINE   AND   INSPECTION   SERVICE.          517 

The  act  approved  April  29,  1878,  entitled  "An  act  to  prevent  the 
introduction  of  contagious  or  infectious  diseases  into  the  United  States," 
provides  that  no  vessel  or  vehicle  coming  from  any  foreign  port  or 
country  where  any  contagious  or  infectious  disease  exists,  or  any  vessel 
or  vehicle  conveying  persons,  merchandise,  or  animals  affected  with  any 
contagious  disease,  shall  enter  any  port  of  the  United  States,  or  pass  the 
boundary-line  between  the  United  States  and  any  foreign  country,  except 
in  such  manner  as  may  be  prescribed  under  said  act.^ 

Attention  is  now  directed  to  the  prevalence  of  the  contagious  and 
infectious  disease  of  small-pox  in  Montreal  and  other  places  in  the  Do- 
minion of  Canada,  and  the  law  referred  to  is  held  to  apply  alike  to  trains 
of  cars  ami  other  vehicles  crossing  the  border,  and  to  vessels  entering 
ports  on  the  northern  frontier. 

Because,  therefore,  of  the  danger  which  attaches  to  the  transporta- 
tion of  persons  and  baggage,  and  articles  of  merchandise,  or  animals, 
from  the  infected  districts,  the  following  regulations  are  framed,  under 
the  direction  of  the  Secretary  of  the  Treasury,  and  subject  to  the  ap- 
proval of  the  President,  for  the  protection  of  the  health  of  the  people  of 
the  United  States  against  the  danger  referred  to : — 

1.  Until  further  orders  all  vessels  arriving  from  ports  in  Canada, 
and  trains  of  cars  and  other  vehicles  crossing  the  border-line,  must  be 
examined  by  a  medical  inspector  of  the  Marine-Hospital  Service  before 
they  will  be  allowed  to  enter  the  United  States,  unless  provision  shall 
have  been  made  by  State  or  municipal  quarantine  laws  and  regulations 
for  such  examination. 

2.  All  persons  arriving  from  Canada,  by  rail  or  otherwise,  must  be 
examined  by  such  medical  inspector  before  they  will  be  allowed  to  enter 
the  United  States,  unless  provision  has  been  made  for  such  examination. 

3.  All  persons  coming  from  infected  districts,  not  giving  satisfac- 
tory evidence  of  protection  against  small-pox,  will  be  prohibited  from 
proceeding  into  the  United  States  until  after  such  period  as  the  medical 
inspector,  the  local  quarantine,  or  other  sanitary  officer  duly  authorized, 
may  direct. 

4.  The  inspectors  will  vaccinate  all  unprotected  persons,  who  desire 
or  are  willing  to  submit  to  vaccination,  free  of  charge.     Any  such  person 
refusing  to  be  vaccinated  shall  be  prevented  from  entering  the  United 
States. 

5.  All  baggage,  clothing,  and  other  effects,  and  articles  of  mer- 
chandise, coming  from  infected  districts,  and  liable  to  carry  infection,  or 
suspected  of  being  infected,  will  be  subjected  to  thorough  disinfection. 

6.  All  persons  showing  evidence  of  having  had  small-pox  or  vario- 
loid,  or  who  exhibit  a  well-defined  mark  of  recent  vaccination,  may  be 


518  TEXT-BOOK    OF    HYGIENE. 

considered  protected ;  but  the  wearing-apparel  and  baggage  of  such  pro- 
tected persons  who  may  come  from  infected  districts,  or  have  been 
exposed  to  infection,  will  be  subjected  to  thorough  disinfection  as  pro- 
vided. 

7.  Customs  officers  and  United  States  medical  inspectors  will  con- 
sult and  act  in  conjunction  with  authorized  State  and  local  health  author- 
ities so  far  as  may  be  practicable,  and  unnecessary  detention  of  trains  or 
other  vehicles,  perfpns,  animals,  baggage,  or  merchandise,  will  be  avoided 
so  far  as  may  be  consistent  with  the  prevention  of  the  introduction  of 
diseases  dangerous  to  the  public  health  into  the  United  States. 

8.  Inspectors  will  make  full  weekly  reports  of  services  performed 
under  this  regulation. 

9.  As  provided  in  Section  5  of  said  act,  all  quarantine  officers  or 
agents  acting  under  any  State  or  municipal  system,  upon  the  application 
of  the  respective  State  or  municipal  authorities,  are  empowered  to  enforce 
the  provisions  of  these  regulations,  and  are  hereby  authorized  to  prevent 
the  entrance  into  the  United   States  of  any' vessel  or  vehicle,  person, 
merchandise,  or  animals  prohibited  under  the  act  aforesaid. 

10.  In  the  enforcement  of  these  regulations  there  shall  be  no  inter- 
ference with  any  quarantine  laws  or  regulations  existing  under  or  to  be 
provided  for  by  any  State  or  municipal  authority. 

The  following  are  the  special  instructions  for  the  guidance 
of  sanitary  inspectors,  issued  by  Surgeon  H.  W.  Austin,  in 
charge  of  the  inspection  service  on  the  Canadian  frontier  from 
Buffalo,  N.  Y.,  to  the  Atlantic  coast  during  the  epidemic  above 
referred  to  (see  Marine-Hospital  Report,  1886): — 

REGULATIONS  FOR  SANITARY  INSPECTORS. 

The  following  instructions  will  be  observed  by  the  sanitary  inspec- 
tor on  the  following-mentioned  railroads  crossing  the  United  States 
boundary-line, — viz.,  the  Grand  Trunk  Railway,  at  Rouse's  Point,  N.  Y., 
and  Island  Pond,  Vt.  ;  the  Passumpsic  Railroad,  at  Newport,  Yt.  ;  the 
Central  Vermont  Railroad,  at  Highgate  Springs  or  Saint  Albans;  the 
Canada  Atlantic,  at  Rouse's  Point,  X.  Y.,  and  the  Southeastern  Rail- 
way, at  Richford,  Yt. : — 

All  persons  bound  for  the  United  States  coming  from  Montreal,  or 
other  places  in  Canada  where  small-pox  prevails,  must  produce  satisfac- 
tory evidence  to  the  inspector  that  they  are  protected  by  a  recent 
vaccination,  or  submit  to  this  operation  before  they  are  allowed  to  cross 
the  boundary -line. 

• 


RAILROAD    QUARANTINE    AND   INSPECTION    SERVICE.  519 

Inspectors  will  vaccinate  all  unprotected  persons  free  of  charge. 

Persons  coming  from  Montreal,  or  suburban  villages,  will  be  care- 
fully questioned  as  to  their  residence,  whether  small-pox  has  occurred  in 
their  families,  or  whether  they  have  been  in  contact  with  the  disease. 

Inquiries  should  also  be  made  relative  to  their  baggage,  whether  it 
consists  of  bedding,  household  goods,  etc.,  likely  to  be  infected;  and  if 
any  person  or  article  of  baggage  is  considered  by  the  inspector  infected 
or  likely  to  introduce  the  disease  into  the  country,  he  or  it  should  not  be 
permitted  to  cross  the  line  into  the  United  States. 

You  may  consider  persons  protected  who  may  show  evidence  of 
having  had  the  small-pox  or  varioloid,  or  who  exhibit  a  well-defined  mark 
of  vaccination.  Accept  as  evidence  of  protection  a  certificate  from  any 
physician  in  good  standing  that  the  person  presenting  the  same  has  been 
successfully  vaccinated.  Should  you  doubt  the  validity  or  authenticity 
of  the  certificate,  you  may  refuse  any  such  person  presenting  the  same 
the  privilege  of  crossing  the  border  unless  he  submits  to  vaccination. 
Baggage  known  to  have  come  from  an}7  infected  district,  and  believed  to 
be  infected,  will  be  thoroughly  fumigated  with  sulphur  at  Rouse's  Point, 
Saint  Albans,  Richford,  Newport,  and  Island  Pond. 

Weekly  reports  should  be  made  to  Surgeon  H.  W.  Austin,  United 
States  Marine-Hospital  Service,  Burlington,  Vt.,  of  the  number  of  trains 
inspected,  number  of  persons  examined,  number  of  persons  vaccinated, 
number  of  pieces  of  baggage  fumigated,  and  any  other  information 
relative  to  services  performed  by  the  inspector. 

It  will  be  observed  that  all  the  railroads,  five  in  number, 
over  which  passengers  or  freight  might  be  brought  direct  from 
Canada  into  the  New  England  States,  were  guarded. 

Besides  the  line  commanded  by  Surgeon  Austin  (Atlantic 
coast  to  Buffalo),  another  line  was  under  the  direction  of  Passed 
Assistant  Surgeon  Wheeler,  at  points  east  of  Buffalo,  and  still 
another  on  the  Michigan  frontier,  under  command  of  Surgeon 
W.  H.  Long.  These  lines  were  established  at  the  request  and 
with  the  co-operation  of  the  authorities  of  the  respective  States. 
Thirty-six  inspectors  were  employed  at  37  stations,  who  exam- 
ined 49,631  persons  on  railroad-trains,  vaccinated  16,547,  and 
detained  or  sent  back  603.  The  contents  of  more  than  7000 
pieces  of  baggage  were  disinfected.  The  measures  taken  were 
successful. 


520  TEXT-BOOK    OF    HYGIENE. 

In  1893,  at  a  time  when  there  was  imminent  danger  that 
cholera  might  be  introduced  into  the  sea-board  cities  of  the 
United  States  and  carried  by  immigrants  to  the  far  West  and 
the  interior  cities  and  towns,  a  most  carefully  formulated  plan 
of  railroad  medical  inspection  of  immigrants  was  drawn  up  ;  and 
while  it  was,  fortunately,  never  necessary  to  carry  out  the  pro- 
visions made  at  the  time,  the  following  regulations  will  well  show 
the  scope  and  general  design  of  the  protective  and  restrictive 
measures  contemplated : — 

RAILROAD  MEDICAL  INSPECTION  OF  IMMIGRANTS. 

TREASURY  DEPARTMENT, 

Office  of  the  Supervising  Surgeon-General  United  States 
Marine- Hospital  Service, 

WASHINGTON,  August  23,  1893. 

Instructions  for  the  Guidance  of  Medical  Officers  of  the  Marine-Hospital 
•  Service,  Sanitary  Inspectors,  and  others  concerned. 

1.  One  or  more  medical   inspectors    shall  accompany  immigrants 
from  the   point  of  departure  of  each   immigrant  train,  and    shall   im- 
mediately commence  making  a  careful  inspection  of  every  passenger — 
man,  woman,  and  child — upon  the  train.     This  inspection  shall  consist  in 
identifying  each  passenger  with  the  health  card  or  cards  he  or  she  may 
hold,  and  satisfying  himself  as  to  the  health  of  each  person  at  the  time 
of  said  inspection.     He  shall  pass  through  the  train  once  every  hour  or 
oftener,  if  he  has  reason  to  believe  any  person  is  suffering  with  diarrhoea 
or  other  symptoms  of  cholera. 

2.  The  railroad  companies  will  be  expected  to  furnish  earth-closets, 
which  should  be  used,  and  the  regular  closets  of  the  car  are  to  be  locked. 
These  earth-closets  shall  be  destroyed,  before  the  train  reaches  its  des- 
tination, at  such  points  as  the  railroad  officials  shall  designate.     It  shall 
be  the  duty  of  the  inspector  to  see  that  the  earth-closets  are  kept  clean 
and  frequently  disinfected,  and  the  cars  properly  ventilated  and  free  from 
all  offensive  odors  and  dirt. 

3.  He  shall,  upon  the  least  suspicion  of  cholera  among  the  immi- 
grants, have  the  suspected  person  or  persons  immediate^  removed  to 
the  hospital  car  at  the  rear  of  the  train,  disinfect  all  ejecta,  and  take 
every  precaution  possible  to  prevent  the  spread  of  the  disease  among  the 
passengers  by  thoroughly  disinfecting  that  portion  of  the  car  occupied 
by  the  suspects,  the  simplest  means  for  this  purpose  being  a  solution  of 
bichloride  of  mercury  in  the  proportion  of  1  to  800. 


INTERSTATE   QUARANTINE.  521 

4.  The  inspectors  will  at  once  notify  the  conductor  of  the  train 
upon  the  first  appearance  of  a  suspicious  case,  in  order  that  the  hospital 
cur  may  be  switched  off  at  the  first  designated  switch,  and  the  health 
officer  of  the  county   in  which  said  switch  is  located  be  immediately 
notified  to  take  charge  of  this  car. 

5.  It  is  expected  that  the  railroads  will  furnish  a  car  for  hospital 
purposes,  in  which  the  seats  can  be  readily  converted  into  beds  suitable 
for  the  care  of  the  sick.     The  necessary  bedding  will  be  furnished  by  the 
United  States  Marine-Hospital  Service. 

6.  Disinfectants,  consisting  of  packages  of  bichloride  of  mercury 
and  an  alkali,  will  be  furnished  the  medical  inspector  in  proper  quantities 
for  adding  to  a  two-gallon  wooden  bucket  of  water;  also  a  quantity  of 
carbolic  acid  in  solution  and  other  approved  disinfectants.    Each  hospital 
car  shall  be  equipped  with  a  dozen  two-gallon  wooden  buckets  for  holding 
disinfecting  ffuids,  half  a  dozen  mops,  one  or  more  hand  force-pumps 
with  rose  sprinklers,  one  or  more  commodes  and  bed-pans,  half  a  dozen 
eight-ounce   hard-rubber   syringes,  half  a   dozen   tumblers,   one   dozen 
rubber  sheets,  and  one  dozen  feeding-cups  for  administering  medicine. 
There  shall  also  be  furnished  an  oil-stove  for  heating  water,  and  several 
tin  boilers  and  tin  cups. 

7.  Medical  supplies,  etc.,  consisting  of  tannic  acid,  hydrarg.  chlori- 
dum  mite,  tincture  of  opium,  mustard  or  mustard  papers,  chloroform  or 
ether  sulph.,  whisky,  brandy,  and  one  or  more  hypodermatic  syringes ; 
also  supply  of  Squibb's  Diarrhoea  Mixture  for  checking  looseness  of  the 
bowels  or  premonitory  diarrhoea. 

WALTER  WYMAN, 
Supervising  Surgeon-General. 

INTERSTATE  QUARANTINE. 

The  general  principles  governing  interstate  quarantine  are 
the  same  as  those  pertaining  to  the  maritime  and  foreign  quar- 
antines, with  the  exception  that,  instead  of  dealing  with  ships  as 
the  media  of  transportation,  we  must  deal  with  trains  on  rail- 
roads, lines  of  stage-coaches,  and  steam-boats  plying  on  the 
inland  waters  of  the  United  States.  The  principles  are  almost 
sufficiently  elahorated  in  the  previous  sections  on  train  inspection 
in  the  case  of  yellow-fever  epidemics,  and  the  precautions  which 
were  under  consideration  for  the  prevention  of  the  spread  of 
cholera  by  means  of  emigrant  trains. 

An  important  matter  is  the  one  of  notification.     It  will  be 


522  TEXT-BOOK   OF   HYGIENE. 

seen,  by  a  study  of  the  regulations  for  interstate  quarantine 
which  follow,  that  State  and  municipal  health  officers  are 
requested  to  notify  the  Supervising  Surgeon-General  of  the  ap- 
pearance of  any  of  the  quarantinable  diseases  in  their  States  or 
localities,  thus  enabling  appropriate  measures  to  be  taken  to 
prevent  their  spread  without  the  loss  of  valuable  time,  for  time 
in  the  management  of  epidemics  is  of  the  utmost  importance. 
Many  an  epidemic  which  has  assumed  vast  proportions  would, 
if  recognized  in  time,  have  been  capable  of  easy  management 
and  of  being  confined  to  the  seat  of  its  first  outbreak.  It  is 
always  comparatively  easy  to  confront  an  open  enemy ;  it  is  the 
insidious  spread  of  disease,  either  unrecognized  or  concealed  for 
reasons  of  business  policy,  that  causes  delay  in  the  inception  of 
preventive  measures,  and  is  most  to  be  dreaded  from  a  sanitary 
stand-point. 

The  following  are  the  regulations  prepared  in  the  Marine- 
Hospital  Bureau  to  prevent  the  introduction  of  contagious  dis- 
eases into  one  State  or  Territory  or  the  District  of  Columbia  from 
another  State  or  Territory  or  District  of  Columbia.  It  is  ex- 
pected that  additional  regulations  will  be  promulgated  from  time 
to  time  as  circumstances  demand : — 

INTERSTATE  QUARANTINE. 
ARTICLE  I. QUARANTINE  DISEASES. 

1.  For  the  purpose  of  these  regulations  the  quarantinable  diseases 
are  cholera  (cholerine),  yellow  fever,  small-pox,  typhus  fever,  leprosy,  and 
plague. 

ARTICLE   II. — NOTIFICATION. 

1.  State  and  municipal  health  officers  should  immediately  notify 
the  Supervising  Surgeon-General  of  the  United  States  Marine-Hospital 
Service,  by  telegraph  or  by  letter,  of  the  existence  of  any  of  the  above- 
mentioned  quarantinable  diseases  in  their  respective  States  or  localities. 

ARTICLE    III. GENERAL    REGULATIONS. 

1.  Persons  suffering  from  a  quarantinable  disease  shall  be  isolated 
until  no  longer  capable  of  transmitting  the  disease  to  others.  Persons 
exposed  to  the  infection  of  a  qunrantinable  disease  shall  be  isolated, 


INTERSTATE   QUARANTINE.  523 

under  observation,  for  such  a  period  of  time  as  may  be  necessary  to 
demonstrate  their  freedom  from  the  disease. 

All  articles  pertaining  to  such  persons,  liable  to  convey  infection, 
shall  be  disinfected  us  hereinafter  provided. 

2.  The  apartments  occupied  by  persons  suffering  from  quarantin- 
able  disease,  and  adjoining  apartnftnts,  when  deemed  infected,  together 
with  articles  therein,  shall  be  disinfected  upon  the  .termination  of  the 
disease. 

3.  Communication  shall  not  be  held  with  the  above-named  persons 
and  apartments,  except  under  tlie  direction  of  a  duly-qualified  officer. 

4.  All  cases  of  quarantinable  disease,  and  all  cases  suspected  of 
belonging  to  this  class,  shall  be  at  once  reported  by  the  physician  in 
attendance  to  the  proper  authorities. 

5.  No  common  carrier  shall  accept  for  transportation  any  person 
suffering  with  a  quarantinable  disease,  nor  any  infected  article  of  clothing, 
bedding,  or  personal  property. 

Bodies  of  persons  who  have  died  from  any  of  the  said  diseases 
shall  not  be  transported  save  in  hermetically-sealed  coffins,  and  by  the 
order  of  the  State  or  local  health  officer. 

6.  In  the  event  of  the  prevalence  of  small-pox,  all  persons  exposed 
to  the  infection,  who  are  not  protected  by  vaccination  or  a  previous 
attack  of  the  disease,  shall  be  at  once  vaccinated  or  isolated  for  a  period 
of  fourteen  days. 

7.  During  the  prevalence  of  cholera,  all  the  dejecta  of  cholera 
patients  shall  be  at  once  disinfected,  as  hereinafter  provided,  t®  prevent 
possible  contamination  of  the  food-  and  water-  supply. 

ARTICLE   IV. — YELLOW   FEVER. 

In  addition  to  the  foregoing  regulations  contained  in  Article  I,  the 
following  special  provisions  are  made  with  regard  to  the  prevention  of 
the  introduction  and  spread  of  yellow  fever  : — 

1.  Localities  infected  with  yellow  fever,  and  localities  contiguous 
thereto,  should  be  depopulated  as  rapidly  and  as  completely  as  possible, 
so  far  as  the  same  can  be  safely  done;  persons  from  non-infected  locali- 
ties, and  who  have  not  been  exposed  to  infection,  being  allowed  to  leave 
without  detention.     Those  who  have  been  exposed,  or  who  came  from 
infected  localities,  shall  be  required  to  undergo  a  period  of  detention  and 
observation  of  ten  days,  from  the  date  of  last  exposure,  in  a  camp  of 
probation  or  other  designated  place. 

Clothing  and  other  articles  capable  of  conveying  infection  shall 
not  be  transported  to  non-infected  localities  without  disinfection. 

2.  Persons  who  have  been  exposed  may  be  permitted  to  proceed 


524  TEXT-BOOK   OF    HYGIENE. 

without  detention  to  places  willing  to  receive  them,  and  incapable  of  be- 
coming infected,  when  arrangements  have  been  perfected  to  the  satisfac- 
tion of  the  proper  health  officer  to  insure  their  detention  in  said  places 
for  a  period  of  ten  days. 

3.  The  suspects  who  are  isolated  under  the  provisions  of  paragraph 
1,  Article  III,  shall  be  kept  free  fronf  all  possibility  of  infection. 

4.  So  far  as  possible  the  sick  should  be  removed  to  a  central  loca- 
tion for  treatment. 

5.  Buildings  in  which  yellow  fever  has  occurred,  and  localities  be- 
lieved to  be  infected  with  said  disease,  must  be  disinfected  as  thoroughly 
as  possible. 

6.  As  soon   as  the  disease  becomes  epidemic,  the  railroad-trains 
carrying  persons  allowed  to  depart  from  the  city  or  place  infected  with 
yellow  fever  shall  be  under  medical  supervision. 

7.  Common  carriers  from  the  infected  districts,  or  believed  to  be 
carrying  persons  and  effects  capable  of  conveying  infection,  shall  be  sub- 
ject to  sanitary  inspection,  and  such  persons  and  effects  shall  not  be 
allowed  to  proceed,  except  as  provided  for  by  paragraph  2. 

8.  At  the  close  of  un  epidemic   the   houses  where   sickness   has 
occurred,  and  the  contents  of  the  same,  and  houses  and  contents  that 
are  presumably  infected,  shall  be  disinfected  as  hereinafter  prescribed. 


ARTICLE   V. — DISINFECTION. 

For  Cholera. 

1.  The  dejecta  and  vomited  matters  of  cholera  patients  shall  be 
received  into  vessels  containing  an  acid  solution  of  bichloride  of  mer- 
cury (bichloride  of  mercury,  1  part ;  hydrochloric  acid,  2  parts ;  water, 
1000  parts)  or  other  efficient  germicidal  agent. 

2.  All  bedding,  clothing,  and  wearing-apparel   soiled  by  the  dis- 
charges of  cholera  patients  shall  be  disinfected  by  one  or  more  of  the 
following  methods  : — 

(a)  Ity  complete  immersion  for  thirty  minutes  in  one  of  the  above- 
named  disinfecting  solutions. 

(6)  By  boiling  for  fifteen  minutes,  all  articles  to  be  completely  sub- 
merged. 

(c)  By  exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  is  reached. 

3.  Any  woodwork  or  furniture  contaminated  by  cholera  discharges 
shall  be  disinfected  by  thorough  washing  with  a  germicidal  solution  as 
provided  in  paragraph  1,  Article  Y. 


INTERSTATE    QUARANTINE.  625 

For   Yellow  Fever. 

4.  Apartments  infected  by  occupancy  of  patients  sick  with  yellow 
fever  shall  be  disinfected  by  one  or  more  of  the  following  methods : — 

(a)  By  thorough  washing  with  one  of  the   germicidal   solutions 
mentioned.     If  apprehension  is  felt  as  to  the  poisonous  effects  of  the 

.mercury,  the  surfaces  may,  after  two  hours,  be  washed  with  clear  water. 

(b)  Thorough  washing  with  a  5-per-cent.  solution  of  pure  carbolic 
acid. 

(c)  By  sulphur  dioxide,  twenty-four  to  forty-eight  hours'  exposure, 
the  apartments  to  be  rendered  as  air-tight  as  possible. 

iv  Bedding,  wearing-apparel,  carpets,  hangings,  and  draperies 
infected  by  yellow  fever  shall  be  disinfected  by  one  of  the  following 
methods : — 

(a)  By  exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  is  reached. 

(6)  By  boiling  for  fifteen  minutes,  all  articles  to  be  completely 
submerged. 

(c)  By  thorough  saturation  in  a  solution  of  bichloride  of  mercury, 
1  to  1000,  the  articles  being  allowed  to  dry  before  washing. 

Articles  injured  by  steam  (rubber,  leather,  containers,  etc.),  to  the 
disinfection  of  which  steam  is  inapplicable,  shall  be  disinfected  by  thor- 
oughly wetting  all  surfaces  with  (a)  a  solution  of  bichloride  of  mercury 
1  to  800,  or  (6)  a  5-per-cent.  solution  of  carbolic  acid,  the  articles  being 
allowed  to  dry  in  the  open  air  prior  to  being  washed  with  water,  or  (c) 
\)y  exposure  to  sulphur  fumigation  in  an  apartment  air-tight,  or  as  nearly 

so  as  possible. 

For  Small-pox. 

6.  Apartments  infected  by  small-pox  shall  be  disinfected  by  one  or 
both  of  the  following  methods : — 

(a)  Exposure  to  sulphur  dioxide  for  twenty-four  to  forty-eight 
hours. 

(6)  Washing  with  a  solution  of  bichloride  of  mercury  1  to  1000,  or  a 
5-per-cent.  solution  of  pure  carbolic  acid. 

7.  Clothing,  bedding,  and  articles  of  furniture  exposed  to  the  infec- 
tion of  small-pox  shall  be  disinfected  by  one  or  more  of  the  following 
methods : — 

(a)  Exposure  to  sulphur  dioxide  for  twenty-four  to  forty-eight 
hours. 

(6)  Immersion  in  a  solution  of  bichloride  of  mercury  1  to  1000,  or 
a  5-per-cent.  solution  of  pure  carbolic  acid. 

(c)  Exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  is  reached. 


526  TEXT-BOOK    OF   HYGIENE. 

(d)  Boiling  for  fifteen  minutes,  the  -articles  to  be  completely  sub- 
merged. 

For  Typhus  Fever. 

8.  Apartments  infected  by  typhus  fever  shall  be  disinfected  by  one 
or  both  of  the  following  methods  : — 

(a)  Exposure  to  sulphur  dioxide  for  twenty-four  to  forty-eight 
hours. 

(6)  Washing  with  a  solution  of  bichloride  of  mercury  1  to  1000,  or  a 
5-per-cent.  solution  of  pure  carbolic  acid. 

9.  Clothing,  bedding,  and  articles  of  furniture  exposed  to  thf  infec- 
tion of  typhus  fever,  shall  be  disinfected  by  one  or  more  of  the  following 
methods : — 

(a)  Exposure  to  sulphur .  dioxide  for  twenty-four  to  forty-eight 
hours. 

(6)  Immersion  in  a  solution  of  bichloride  of  mercury  1  to  1000,  or  a 
5-per-cent.  solution  of  pure  carbolic  acid. 

(c)  Exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  is  reached. 

(d)  Boiling  for  fifteen  minutes,  the  articles  to  be  completely  sub- 
merged. 

MUNICIPAL  QUARANTINE. 

It  is  now  generally  conceded  that  a  small  number  of  cases 
of  certain  ones  of  the  quarantinable  diseases  may  exist  in  a  city 
of  considerable  size,  without  giving  rise  to  serious  apprehension, 
if  intelligent  and  vigorous  measures  for  the  prevention  of  its 
spread  are  taken,  and  if  scientific  measures  for  the  isolation  of 
patients,  the  surveillance  of  those  exposed  to  infection,  and  the 
disinfection  of  apartments  and  articles  infected  are  carried  out. 
It  is  regarded  as  very  important  that  the  sick  should  be  removed 
to  centrally-located  hospital  establishments  for  treatment,  thus 
increasing  ease  of  management  and  administration,  and  dimin- 
ishing the  number  of  foci  of  infection.  The  surveillance  of 
those  exposed  to  infection  should,  in  general,  be  for  a  period  of 
time  equal  to  the  usual  period  of  incubation  of  the  disease  to 
which  they  have  been  exposed.  In  the  case  of  small-pox  it  may 
be  unnecessary  at  times  to  detain  the  suspects  the  full  period  of 
incubation,  provided  they  are  vaccinated  and  their  clothing  and 


MUNICIPAL   QUARANTINE.  527 

personal  effects  are  rendered  safe  by  efficient  disinfection.    They 
should,  however,  be  kept  under  observation. 

For  the  suppression  of  small-pox  in  cities  in  which  it  has 
made  its  appearance,  and  in  which  it  threatens  to  become  epi- 
demic, the  following  suggestions,  made  by  the  health  authorities 
of  the  Northwest,  will  undoubtedly  prove  of  value : — 

1.  The  city  should  be  divided  into  districts  containing  not  more 
than  10,000  people. 

2.  Each  district  should  be  placed  under  the  supervision  of  a  compe- 
tent medical  inspector  with  necessary  assistants  (a)  to  make  a  house- 
to-house  inspection  ;  (6)  to  successfully  vaccinate,  within  the  shortest 
possible  time,  all  persons  who  have  not  been  vaccinated  during  the  out- 
break, the  first  vaccination  to  be  completed  within  seven  days ;  (c)  to 
properly  disinfect  all  houses  and  their  contents  where  small-pox  occurs. 

3.  Necessary  means  and  appliances  for  efficient  disinfection  of  ma- 
terials, premises,  etc.,  should  be  provided  as  the  exigencies  of  each  district 
may  require. 

4.  Each  case  of  small-pox   should  be  immediately  removed  to  a 
suitably    constructed   and    properly    equipped    and    officered   isolation 
hospital. 

5.  Except  in  extreme  cold  weather,  hospital  tents,  as  prescribed  in 
the  United  States  Army  Regulations,  floored  and  warmed,  are  preferable 
to  the  average  hospital  or  private  dwelling,  and  increase  the  chances  of 
recovery  of  the  patients.     Cases  of  small-pox  necessarily  retained  in  their 
own  homes  should,  with  their  attendants,  be  rigidly  isolated  during  the 
period  of  danger,  and  physicians  visiting  such  patients  professionally 
should  be  subject  to  such  regulations  as  may  be  prescribed  by  the  local 
health  officer. 

6.  Persons  exposed  to  small-pox  contagion  should  be  immediately 
vaccinated  and  kept  under  observation  for  not  less  than  fourteen  days 
from  time  of  last  exposure. 

7.  It  is  the  sense  of  this  Conference  that  unless  such  measures  are 
enforced,  it  will  be  necessary  for  neighboring  cities  and  States  to  exclude 
all  persons  from  such  city  who  are  not  protected  against  small-pox  by 
recent  vaccination,  and  to  require  proper  disinfection  of  all  clothing,  bag- 
gage, and  merchandise  capable  of  conveying  small-pox  infection. 

The  subject  of  municipal  quarantine  naturally  suggests  a 
subdivision  of  the  subject,  viz.,  domiciliary  quarantine,  or  the  ex- 
ercise of  restrictive  measures  against  a  particular  house  or  part 


528  TEXT-BOOK   OF    HYGIENE. 

of  a  house  on  account  of  the  occurrence  of  a  quarantinable  dis- 
ease within  its  limits.  These  can  best  be  accomplished  by  the 
stationing  of  guards  to  see  that  none  enter  or  leave  the  infected 
premises  except  those  necessary  to  care  for  the  sick,  viz.,  phy- 
sicians and  nurses.  All  intercourse  between  the  outside  world 
and  the  house  under  quarantine  should  be  carried  on  by 
messengers  who  should  not  be  allowed  to  enter  the  premises, 
but  who  should  report  to  the  guards. 

It  would  be  most  desirable  that  the  physicians  and  nurses, 
on  leaving  the  premises,  should  practice  personal  disinfection  of 
hands,  at  least;  though,  of  course,  it  would  be  better  if,  in  ad- 
dition to  this,  a  change  into  sterile  clothing  were  made  prior  to 
coming  into  contact  with  the  public. 

It  goes  without  saying  that  the  room  of  the  patient  should 
be  absolutely  closed  to  the  ingress  of  all  save  the  physicians  and 
nurses,  and  it  is  a  practice  of  considerable  value  to  provide  all 
room-openings  with  curtains  or  hangings,  which  are  to  be  kept 
constantly  wet  with  a  germicidal  solution.  The  dejecta,  vomited 
matter,  and  sputum  should  be  promptly  disinfected  according  to 
circumstances.  When  the  disease  has  terminated,  the  house  or 
apartments  are  to  be  thoroughly  disinfected  by  one  of  the 
methods  prescribed  in  the  regulations,  the  method  chosen  being 
adapted  to  the  disease  which  has  prevailed.  For  the  purposes 
of  municipal  disinfection  the  Marine-Hospital  Service  has  had 
constructed  portable  apparatus  for  the  use  of  steam  and  sulphur, 
which  are,  in  effect,  the  same  apparatus  as  have  been  previously 
described  in  this  article,  modified  to  meet  their  special  require- 
ments. 

An  important  factor  in  the  measures  taken  to  suppress  any 
epidemic  disease  is  a  house-to-house  inspection,  to  ascertain 
the  actual  number  of  cases  existing.  Whether  this  inspection 
should  include  the  whole  city,  or  only  the  infected  district,  is  a 
matter  for  the  exercise  of  judgment ;  but,  when  required,  the  in- 
spections should  be  made  at  intervals  corresponding  with  the 
usual  periods  of  incubation  of  the  disease  under  observation. 


DIPHTHERIA    AND    SCARLET   FEVER.  529 

A  very  important  field  for  the  exercise  of  municipal  and 
domiciliary  quarantine  is  furnished  by  those  contagious  and  in- 
fectious diseases  which,  while  causing  large  mortality,  seldom 
prevail  in  epidemic  form,  viz.,  measles,  scarlet  fever,  diphtheria, 
and  tuberculosis. 

MEASLES. 

Measles  may  be  dismissed  with  a  few  words.  The  course 
of  the  disease,  uncomplicated,  is  usually  so  benign,  especially  in 
children,  that  all  that  is  necessary  is  isolation.  At  the  conclusion 
of  the  case  or  cases  the  apartment  should  be  well  aired,  and  it 
may  be  advisable  to  subject  the  room  and  the  contents,  bedding, 
and  clothing  to  fumigation  by  sulphur. 

DIPHTHERIA    AND    SCARLET   FEVER. 

With  diphtheria  and  scarlet  fever  the  conditions  are  far 
different.  The  diseases  are  virulent:  the  infection  is  subtle,  and 
their  spread  very  much  to  be  dreaded.  Vigorous  effort  alone  can 
prevent  their  spread.  Dwellings  where  the  disease  prevails 
must  be  placarded,  special  hospitals  should  be  provided,  and 
disinfection  should  be  intelligently  performed  by  competent 
municipal  authority. 

The  regulations  of  the  Board  of  Health  of  the  District  of 
Columbia  are  given  here,  as  embodying  the  most  recent  practice 
in  the  management  of  these  diseases : — 

REGULATIONS  TO  PREVENT  THE  SPREAD  OF  DIPHTHERIA  AND  SCARLET 

FEVER. 

The  following  regulations,  provided  for  in  the  Act  of  Congress 
approved  December  20,  1890,  are  promulgated  for  the  information  of  all 
concerned  : 

The  act  referred  to  provides,  in  Section  2,  "  That  it  shall  be  the 
duty  of  the  health  officer,  in  conjunction  with  the  attending  physician, 
to  cause  the  premises  to  be  properly  disinfected,  and  to  issue  the  neces- 
sary instructions  for  the  isolation  of  the  patient  ";  in  Section  3,  "  That 
it  shall  be  the  duty  of  physicians,  while  in  attendance  upon  cases  of 
scarlet  fever  and  diphtheria,  to  exercise  such  reasonable  precautions  to 
prevent  the  spread  of  the  said  diseases  as  may  be  prescribed  by  the 

34 


530  TEXT-BOOK    OF    HYGIENE. 

health  officer  of  the  District  of  Columbia  in  regulations  " ;  in  Section  6, 
"  That  the  word  '  regulations,'  as  herein  used,  shall  be  held  to  mean,  also, 
rules,  orders,  and  amendments." 

The  term  "  scarlet  fever,"  as  applied  in  the  act,  shall  be  held  to  in- 
clude scarlatina,  scarlet  rash,  and  canker  rash,  and  each  and  every  case 
must  be  reported  upon  the  forms  provided. 

Warning-signs  shall  remain  displayed  on  houses,  in  cases  of  scarlet 
fever,  for  a  period  of  not  less  than  four  weeks,  and  in  cases  of  diphtheria 
for  not  less  than  three  weeks  from  date  of  report  to  the  health  officer, 
and  for  a  longer  period,  unless  report  of  recovery  by  the  physician  in 
attendance  has  been  made. 

In  cases  of  death,  the  warning-sign  shall  remain  displayed  upon 
premises  for  a  period  of  not  less  than  seven  days,  and  longer,  unless  the 
health  officer  is  satisfied  that  all  proper  means  have  been  employed  for 
prevention  of  the  spread  of  the  contagion. 

It  shall  be  the  duty  of  the  householder,  in  every  case  where  a 
warning-sign  has  been  displayed  from  the  premises  which  he  or  she  occu- 
pies, to  report  prompt!}-  the  removal  of  such  sign  at  any  time  within  the 
periods  given. 

It  shall  be  the  like  duty  of  the  physician  in  attendance  to  make 
such  report  to  the  health  officer  of  the  removal  of  warning-signs,  unless 
assured  that  the  report  has  been  made  by  some  one  from  the  premises 
where  the  disease  is  prevailing  or  has  prevailed. 

It  shall  be  the  duty  of  the  physician  in  attendance  to  report,  in 
every  instance,  on  the  forms  provided,  whether  or  not  children  in  the 
family  or  other  children  in  the  same  building  attend  school,  and  at  what 
school-building  or  buildings. 

Children  shall  not  be  permitted  to  return  to  school  from  infected 
premises,  except  upon  presentation  of  the  proper  certificate  from  the 
health  officer. 

All  persons  suffering  from  either  diphtheria  or  scarlet  fever  are  to 
be  isolated  in  rooms  as  far  removed  as  possible  from  those  occupied  by 
other  persons  in  the  building,  and  upon  the  top  floor,  where  it  is  prac- 
ticable. No  person,  other  than  the  physician  in  attendance,  the  examin- 
ing official,  and  the  nurse  or  nurses,  shall  be  admitted  to  such  room 
during  the  prevalence  of  the  disease. 

Every  room  occupied  by  a  patient  suffering  from  either  diphtheria 
or  scarlet  fever  shall  be  cleared  of  all  needless  clothing,  carpets,  drapery, 
and  other  materials  likely  to  harbor  the  poisons  of  the  disease. 

Soiled  bed-  and  body-  linen  shall  be  immediately  placed  in  vessels 
of  water  containing  a  solution  of  bichloride  of  mercury,  chloride  of  zinc, 
or  other  suitable  disinfectant. 


DIPHTHERIA    AND    SCARLET   FEVER.  531 

Excremental  discharges  from  the  patient  shall  be  received  in  vessels 
of  water  containing  such  a  solution,  and  all  vessels  used  shall  be  kept 
scrupulously  clean  and  thoroughly  disinfected. 

Discharges  from  the  throat,  nose,  and  mouth  shall  be  received  upon 
pieces  of  cloth,  which  must  be  immediately  burned. 

All  persons  recovering  from  either  diphtheria  or  scarlet  fever  shall 
be  considered  dangerous,  and  shall  not  be  permitted  to  associate  with 
others,  or  to  attend  school,  church,  or  any  public  assembly,  until  a  cer- 
tificate has  been  furnished  by  the  health  officer  to  the  effect  that  they 
may  go  abroad  without  danger  of  disseminating  the  contagion. 

It  shall  be  the  duty  of  the  person  in  charge  of  the  premises  where 
a  case  of  diphtheria  or  scarlet  fever  exists,  to  exercise  all  reasonable  care 
in  the  prevention  of  the  commingling  of  persons  who  come  into  contact 
with  the  patient,  or  any  other  persons,  whereby  the  contagion  might  be 
disseminated. 

The  body  of  a  person  who  has  died  from  either  diphtheria  or  scarlet 
fever  shall  be  immediately  disinfected  and  placed  in  a  coffin,  which  shall 
be  tightly  closed,  and  shall  not  be  taken  to  any  church  or  place  of  public 
assembly,  and  shall  be  buried  within  forty -eight  hours,  unless  otherwise 
ordered  by  the  health  officer. 

No  public  funeral  shall  be  held  in  a  dwelling  in  which  there  is  a 
case  of  either  diphtheria  or  scarlet  fever,  nor  in  which  a  death  from  either 
of  said  diseases  has  recently  occurred. 

Immediately  upon  the  recovery  of  a  person  who  has  been  suffering 
from  either  diphtheria  or  scarlet  fever,  or  upon  the  death  of  a  person 
who  has  been  so  suffering,  the  room  or  rooms  occupied  shall  be 
thoroughly  disinfected  by  exposure  for  several  hours  to  the  fumes  of 
chlorine  gas,  or  of  burning  sulphur,  and  shall  thereafter  be  thoroughly 
cleaned  and  exposed  to  currents  of  fresh  air. 

All  clothing,  bedding,  carpets,  and  other  textiles  which  have  been 
exposed  to  the  contagion  of  the  disease  shall  be  either  burned,  exposed 
to  superheated  steam,  or  thoroughly  boiled. 

No  person  shall  interfere  with  or  obstruct  the  entrance,  inspection, 
and  examination  of  any  building  or  house,  by  the  inspectors  or  officers 
of  this  department,  when  there  has  been  reported  the  case  of  a  person 
sick  with  either  scarlet  fever  or  diphtheria  therein. 

Diagnosis  of  Diphtheria. — For  the  more  prompt  and  cer- 
tain diagnosis  of  diphtheria,  small  wooden  boxes  are  distributed 
to  the  various  pharmacies  in  Washington,  each  box  holding  two 
glass  tubes,  one  tube  containing  a  small  cotton  swab,  the  other 


532  TEXT-BOOK   OF    HYGIENE. 

containing  solidified  blood-serum  as  a  culture  medium.  Each 
tube  is  sterilized  and  plugged  with  cotton.  The  following 
notice  is  inclosed  in  each  box : — 

DIRECTIONS  FOR  MAKING  CULTURES  IN  SUSPECTED  CASES  OF  DIPHTHERIA. 

The  patient  should  be  placed  in  the  best  light  attainable,  and,  if  a 
child,  property  held.  In  cases  where  it  is  possible  to  get  a  good  view  of 
the  throat,  depress  the  tongue  and  rub  the  cotton  swab  gently,  but  freely, 
against  any  visible  pseudomembrane  or  exudate.1 

In  other  cases,  including  those  in  which  the  exudate  is  confined  to 
the  larynx,  open  the  mouth  and  pass  the  swab  back  till  it  reaches  the 
pharynx,  and  then  rub  it  freely  against  the  mucous  membrane.  Without 
laying  the  swab  down,  withdraw  the  cotton  plug  from  the  culture-tube, 
insert  the  swab,  and  rub  that  portion  of  it  which  has  touched  the  exudate 
gently  back  and  forth  along  the  surface  of  the  blood-serum.  Then 
replace  the  swab  in  its  own  tube,  plug  both  tubes,  and  send  the  whole 
outfit  at  once  to  the  laboratory. 

A  report  will  be  forwarded  the  following  morning,  by  mail,  or  can 
be  obtained  by  telephone. 

TUBERCULOSIS. 

With  the  discovery  by  Koch  of  the  cause  of  tuberculosis, 
and  the  numerous  researches  made  by  him  and  other  observers 
into  the  nature  of  the  tuberculous  poison,  has  grown  the  con- 
viction, of  late  years,  that  tuberculosis,  being  communicable, 
is  to  a  large  extent  preventable.  The  bacillus  tuberculosis  is 
the  etiological  factor  of  most  importance  in  the  spread  of  tuber- 
culosis ;  it  has  been  proved  that  it  is  contained  in  large  numbers 
in  the  sputum  of  tuberculous  patients,  and  that,  unlike  most 
micro-organisms,  its  vitality  is  not  destroyed  by  drying.  There- 
fore, with  the  careful  disinfection  or  destruction  of  the  expecto- 
ration of  tuberculous  patients,  one  most  important  factor  in  the 
dissemination  of  tuberculosis  will  be  removed.  In  almost  all 
large  hospitals,  at  the  present  day,  the  practice  obtains  of  either 
isolating  the  tuberculous  patients  or  of  segregating  them  in 
special  wards  or  apartments.  With  a  view  of  preventing  the 
spread  of  tuberculosis,  the  Board  of  Health  of  New  York  City 

1  This  should  be  done  before  any  germicide  lias  been  applied,  and,  if  this  has  been  done, 
allow  at  least  an  hour  to  intervene  before  making  the  inoculation. 


TUBERCULOSIS.  533 

has  issued  in  English,  German,  Hebrew,  and  Italian  the  follow- 
ing circular  for  popular  instruction : — 

Consumption  is  a  disease  which  can  be  taken  from  others,  and  is 
not  simply  caused  by  colds.  A  cold  may  make  it  easier  to  take  the  dis-  . 
ease.  It  is  usually  caused  by  germs  which  enter  the  body  with  the  air 
breathed.  The  matter  which  consumptives  cough  or  spit  up  contains 
these  germs  in  great  numbers ;  frequently  millions  are  discharged  in  a 
single  day.  This  matter,  spit  upon  the  floor,  wall,  or  elsewhere,  is  apt 
to  dry,  become  pulverized,  and  float  in  the  air  as  dust.  This  dust  con- 
tains the  germs,  and  thus  they  enter  the  body  with  the  air  breathed. 
The  breath  of  a  consumptive  does  not  contain  the  germs,  and  will  not 
produce  the  disease.  A  well  person  catches  the  disease  from  a  con- 
sumptive only  by  in  some  way  taking  the  matter  coughed  up  by  the 
consumptive. 

Consumption  can  often  be  cured  if  its  nature  is  recognized  early 
and  proper  means  are  taken  for  its  treatment.  In  a  majority  of  cases  it 
is  not  a  fatal  disease. 

It  is  not  dangerous  for  other  persons  to  live  with  a  consumptive  if 
the  matter  coughed  up  by  the  consun\ptive  is  at  once  destroyed.  This 
matter  should  not  be  spit  upon  the  floor,  carpet,  stove,  wall,  or  street,  or 
anywhere  except  into  a  cup  kept  for  that  purpose.  The  cup  should  con- 
tain water,  so  that  the  matter  may  not  dry,  and  should  be  emptied  into 
the  closet  at  least  twice  a  day,  and  carefully  washed  with  hot  water. 
Great  care  should  be  taken  by  a  consumptive  that  his  hands,  face,  and 
clothing  do  not  become  soiled  with  the  matter  coughed  up.  If  they  do 
become  soiled,  they  should  be  at  once  washed  with  hot  water  and  soap. 
When  consumptives  are  away  from  home,  the  matter  coughed  up  may  be 
received  on  cloths,  which  should  be  at  once  burned  on  returning  home. 
If  handkerchiefs  are  used  (worthless  cloths  which  can  be  burned  are 
far  better),  they  should  be  boiled  in  water  by  themselves  before  being 
washed. 

It  is  better  for  a  consumptive  to  sleep  alone,  and  his  bed-clothing 
and  personal  clothing  should  be  boiled  and  washed  separately  from  the 
clothing  belonging  to  other  people. 

Whenever  a  person  is  thought  to  be  suffering  from  consumption, 
the  name  and  address  should  be  sent  at  once  to  the  health  department, 
on  a  postal  card,  with  a  statement  of  this  fact.  A  medical  inspector 
from  the  health  department  will  then  call  and  examine  the  person  to  see 
if  he  has  consumption,  providing  he  has  no  physician,  and,  if  necessary, 
will  give  proper  direction  to  prevent  others  from  catching  the  disease. 

Frequently  a   person   suffering   from  consumption  may  not   only 


534  TEXT-BOOK    OF    HYGIENE. 

do  bis  usual  work  without  giving  the  disease  to  others,  but  may  also  get 
well,  if  the  matter  coughed  up  is  properly  destroyed. 

Rooms  that  have  been  occupied  by  consumptives  should  be  thor- 
oughly cleaned,  scrubbed,  whitewashed,  painted  or  papered  before  they 
are  again  occupied.  Carpets,  rugs,  bedding,  etc.,  from  rooms  which 
have  been  occupied  by  consumptives,  should  be  disinfected.  The  health 
department  should  be  notified,  when  they  will  be  sent  for,  disinfected, 
and  returned  to  the  owner  free  of  charge  ;  or,  if  he  so  desire,  they  will 
be  destroyed. 

QUARANTINE   LAWS   OF   THE    UNITED    STATES. 

AN  ACT   granting  additional  quarantine   powers   and   imposing  additional  duties  upon 
the  Marine-Hospital  Service. 

[Approved  February  15,  1893.] 

Be  it  enacted  by  the  Senate  and  House  of  Representatives  of  the 
United  States  of  America  in  Congress  assembled,  That  it  shall  be  unlaw- 
ful for  any  merchant  ship  or  other  vessel  from  any  foreign  port  or  place 
of  [to]  enter  any  port  of  the  United  States  except  in  accordance  with 
the  provisions  of  this  act  and  with  such  rules  and  regulations  of  State 
and  municipal  health  authorities,  as  may  be  made  in  pursuance  of,  or 
consistent  with,  this  act ;  and  any  such  vessel  which  shall  enter,  or 
attempt  to  enter,  a  port  of  the  United  States  in  violation  thereof  shall 
forfeit  to  the  United  States  a  sura,  to  be  awarded  in  the  discretion  of  the 
court,  not  exceeding  five  thousand  dollars,  which  shall  be  a  lien  upon 
said  vessel,  to  be  recovered  by  proceedings  in  the  proper  district  court 
of  the  United  States.  In  all  such  proceedings  the  United  States  Dis- 
trict Attorney  for  such  district  shall  appear  on  behalf  of  the  United 
States ;  and  all  such  proceedings  shall  be  conducted  in  accordance  with 
the  rules  and  laws  governing  cases  of  seizure  of  vessels  for  violation  of 
the  revenue  laws  of  the  United  States. 

SEC.  2.  That  any  vessel  at  any  foreign  port  clearing  for  any  port  or 
place  in  the  United  States  shall  be  required  to  obtain  from  the  consul, 
vice-consul,  or  other  consular  officer  of  the  United  States  at  the  port  of 
departure,  or  from  the  medical  officer  where  such  officer  has  been  de- 
tailed by  the  President  for  that  purpose,  a  bill  of  health,  in  duplicate,  in 
the  form  prescribed  by  the  Secretary  of  the  Treasun-,  setting  forth  the 
sanitary  history  and  condition  of  said  vessel,  and  that  it  has  in  all  re- 
spects complied  with  the  rules  and  regulations  in  such  cases  prescribed 
for  securing  the  best  sanitary  condition  of  the  said  vessel,  its  cargo, 
passengers,  and  crew  ;  and  said  consular  or  medical  officer  is  required, 
before  granting  such  duplicate  bill  of  health,  to  be  satisfied  that  the 
matters  and  things  therein  stated  are  true ;  and  for  his  services  in  that 


QUARANTINE   LAWS   OF   THE    UNITED    STATES.  535 

behalf  he  shall  be  entitled  to  demand  and  receive  such  fees  as  shall  by 
lawful  regulation  be  allowed,  to  be  accounted  for  as  is  required  in  other 
cases. 

The  President,  in  his  discretion,  is  authorized  to  detail  any  medical 
officer  of  the  government  to  serve  in  the  office  of  the  consul  at  any 
foreign  port  for  the  purpose  of  furnishing  information  and  making  the 
inspection  and  giving  the  bills  of  health  hereinbefore  mentioned.  Any 
vessel  clearing  and  sailing  from  any  such  port  without  such  bill  of 
health,  and  entering  any  port  of  the  United  States,  shall  forfeit  to  the 
United  States  not  more  than  five  thousand  dollars,  the  amount  to  be 
determined  by  the  court,  which  shall  be  a  lien  on  the  same,  to  be  recov- 
ered by  proceedings  in  the  proper  district  court  of  the  United  States. 
In  all  such  proceedings  the  United  States  District  Attorney  for  such  dis- 
trict shall  appear  on  behalf  of  the  United  States  ;  and  all  such  proceed- 
ings shall  be  conducted  in  accordance  with  the  rules  and  laws  governing 
cases  of  seizure  of  vessels  for  violation  of  the  revenue  laws  of  the  United 
States. 

SEC.  3.  That  the  Supervising  Surgeon-General  of  the  Marine-Hos- 
pital Service  shall,  immediately  after  this  act  takes  effect,  examine  the 
quarantine  regulations  of  all  State  and  municipal  boards  of  health,  and 
shall,  under  the  direction  of  the  Secretary  of  the  Treasury,  co-operate 
with  and  aid  State  and  municipal  boards  of  health  in  the  execution  and 
enforcement  of  the  rules  and  regulations  of  such  boards  and  in  the  ex- 
ecution and  enforcement  of  the  rules  and  regulations  made  by  the  Sec- 
retary of  the  Treasury  to  prevent  the  introduction  of  contagious  or 
infectious  diseases  into  the  United  States  from  foreign  countries,  and 
into  one  State  or  Territory  or  the  District  of  Columbia  from  another 
State  or  Territory  or  the  District  of  Columbia ;  and  all  rules  and  reg- 
ulations made  by  the  Secretary  of  the  Treasury  shall  operate  uniformly 
and  in  no  manner  discriminate  against  any  port  or  place ;  and  at  such 
ports  and  places  within  the  United  States  as  have  no  quarantine  reg- 
ulations under  State  or  municipal  authority,  where  such  regulations  are, 
in  the  opinion  of  the  Secretary  of  the  Treasury,  necessary  to  prevent 
the  introduction  of  contagious  or  infectious  diseases  into  the  United 
States  from  foreign  countries,  pr  into  one  State  or  Territory  or  the  Dis- 
trict of  Columbia  from  another  State  or  Territory  or  the  District  of 
Columbia,  and  at  such  ports  and  places  within  the  United  States  where 
quarantine  regulations  exist  under  the  authority  of  the  State  or  munici- 
pality which,  in  the  opinion  of  the  Secretary  of  the  Treasury,  are  not 
sufficient  to  prevent  the  introduction  of  such  diseases  into  the  United 
States,  or  into  one  State  or  Territory  or  the  District  of  Columbia  from 
another  State  or  Territory  or  the  District  of  Columbia,  the  Secretary  of 


536  TEXT-BOOK   OF   HYGIENE. 

the  Treasury  shall,  if  in  his  judgment  it  is  necessary  and  proper,  make 
such  additional  rules  and  regulations  as  are  necessary  to  prevent  the  in- 
troduction of  such  diseases  into  the  United  States  from  foreign  countries, 
or  into  one  State  or  Territory  or  the  District  of  Columbia  from  another 
State  or  Territory  or  the  District  of  Columbia;  and  when  said  rules  and 
regulations  have  been  made  they  shall  be  promulgated  by  the  Secretary 
of  the  Treasury  and  enforced  by  the  sanitary  authorities  of  the  States  and 
municipalities,  where  the  State  or  municipal  health  authorities  will  un- 
dertake to  execute  and  enforce  them  ;  but  if  the  State  or  municipal  au- 
thorities shall  fail  or  refuse  to  enforce  said  rules  and  regulations,  the 
President  shall  execute  and  enforce  the  same  and  adopt  such  measures 
as  in  his  judgment  shall  be  necessary  to  prevent  the  introduction  or 
spread  of  such  diseases,  and  may  detail  or  appoint  officers  for  that  pur- 
pose. The  Secretary  of  the  Treasury  shall  make  such  rules  and  regula- 
tions as  are  necessar}^  to  be  observed  by  vessels  at  the  port  of  departure 
and  on  the  voyage,  where  such  vessels  sail  from  any  foreign  port  or  place 
to  any  port  or  place  in  the  United  States,  to  secure  the  best  sanitary 
condition  of  such  vessel,  her  cargo,  passengers,  and  crew ;  which  shall  be 
published  and  communicated  to  and  enforced  by  the  consular  officers  of 
the  United  States.  None  of  the  penalties  herein  imposed  shall  attach  to 
any  vessel  or  owner  or  officer  thereof  until  a  copy  of  this  act,  with  the 
rules  and  regulations  made  in  pursuance  thereof,  has  been  posted  up  in 
the  office  of  the  consul  or  other  consular  officer  of  the  United  States  for 
ten  days,  in  the  port  from  which  said  vessel  sailed ;  and  the  certificate 
of  such  consul  or  consular  officer  over  his  official  signature  shall  be 
competent  evidence  of  such  posting  in  any  court  of  the  United  States. 

SEC.  4.  That  it  shall  be  the  duty  of  the  Supervising  Surgeon-Gen- 
eral of  the  Marine-Hospital  Service,  under  the  direction  of  the  Secretary 
of  the  Treasury,  to  perform  all  the  duties  in  respect  to  quarantine  and 
quarantine  regulations  which  are  provided  for  by  this  act,  and  to  obtain 
information  of  the  sanitary  condition  of  foreign  ports  and  places  from 
which  contagious  and  infectious  diseases  are  or  may  be  imported  into  the 
United  States ;  and  to  this  end  the  consular  officer  of  the  United  States, 
at  such  ports  and  places  as  shall  be  designated  by  the  Secretary  of  the 
Treasury,  shall  make  to  the  Secretary  of  the  Treasurj'  weekly  reports  of 
the  sanitary  condition  of  the  ports  and  places  at  which  they  are  respect- 
ively stationed,  according  to  such  forms  as  the  Secretary  of  the  Treasury 
shall  prescribe ;  and  the  Secretary  of  the  Treasury  shall  also  obtain, 
through  all  sources  accessible,  including  State  and  municipal  sanitary 
authorities  throughout  the  United  States,  weekly  reports  of  the  sanitiuy 
condition  of  ports  and  places  within  the  United  States,  and  shall  pre- 
pare, publish,  and  transmit  to  collectors  of  customs  and  to  State  and 


QUARANTINE    LAWS   OF    THE    UNITED    STATES.  537 

municipal  health  officers  and  other  sanitarians  weekly  abstracts  of  the 
consular  sanitary  reports  and  other  pertinent  information  received  by 
him ;  and  shall  also,  as  far  as  he  may  be  able,  by  means  of  the  voluntary 
co-operation  of  State  and  municipal  authorities,  of  public  associations, 
and  private  persons,  procure  information  relating  to  the  climatic  and 
other  conditions  affecting  the  public  health,  and  shall  make  an  annual 
report  of  his  operations  to  Congress,  with  such  recommendations  as  he 
may  deem  important  to  the  public  interests. 

SEC.  5.  That  the  Secretary  of  the  Treasury  shall  from  time  to  time 
issue  to  the  consular  officers  of  the  United  States  and  to  the  medical 
officers  serving  at  any  foreign  port,  and  otherwise  make  publicly  known, 
the  rules  and  regulations  made  by  him,  to  be  used  and  complied  with  by 
vessels  in  foreign  ports,  for  securing  the  best  sanitary  condition  of  such 
vessels,  their  cargoes,  passengers,  and  crew,  before  their  departure  for 
any  port  in  the  United  States,  and  in  the  course  of  the  voyage ;  and  all 
such  other  rules  and  regulations  as  shall  be  observed  in  the  inspection 
of  the  same  on  the  arrival  thereof  at  any  quarantine  station  at  the  port 
of  destination,  and  for  the  disinfection  and  isolation  of  the  same,  and  the 
treatment  of  cargo  and  persons  on  board,  so  as  to  prevent  the  introduc- 
tion of  cholera,  yellow  fever,  or  other  contagious  or  infectious  diseases ; 
and  it  shall  not  be  lawful  for  any  vessel  to  enter  said  port  to  discharge 
its  cargo  or  land  its  passengers,  except  upon  a  certificate  of  the  health 
officer  at  such  quarantine  station  certifying  that  said  rules  and  regula- 
tions have  in  all  respects  been  observed  and  complied  with,  as  well  on 
his  part  as  on  the  part  of  the  said  vessel  and  its  master,  in  respect  to  the 
same  and  to  its  cargo,  passengers,  and  crew ;  and  the  master  of  every 
such  vessel  shall  produce  and  deliver  to  the  collector  of  customs  at  said 
port  of  entry,  together  with  the  other  papers  of  the  vessel,  the  said  bills 
of  health  required  to  be  obtained  at  the  port  of  departure  and  the  cer- 
tificate herein  required  to  be  obtained  from  the  health  officer  at  the  port 
of  entry ;  and  that  the  bills  of  health  herein  prescribed  shall  be  con- 
sidered as  part  of  the  ship's  papers,  and  when  duly  certified  to  by  the 
proper  consular  officer  or  other  officer  of  the  United  States,  over  his 
official  signature  and  seal,  shall  be  accepted  as -evidence  of  the  statements 
therein  contained  in  any  court  of  the  United  States. 

SEC.  6.  That  on  the  arrival  of  an  infected  vessel  at  any  port  not 
provided  with  proper  facilities  for  treatment  of  the  same,  the  Secretary 
of  the  Treasury  may  remand  said  vessel,  at  its  own  expense,  to  the 
nearest  national  or  other  quarantine  station,  where  accommodations  and 
appliances  are  provided  for  the  necessary  disinfection  and  treatment  of 
the  vessel,  passengers,  and  cargo ;  and  after  treatment  of  any  infected 
vessel  at  a  national  quarantine  station,  and  after  certificate  shall  have 


TEXT-BOOK    OF    HYGIENE. 

been  given  by  the  United  States  quarantine  officer  at  said  station  that 
the  vessel,  cargo,  and  passengers  are  each  and  all  free  from  infectious 
disease,  or  danger  of  conveying  the  same,  said  vessel  shall  be  admitted 
to  entry  to  any  port  of  the  United  States  named  within  the  certificate. 
But  at  any  ports  where  sufficient  quarantine  provision  has  been  made 
by  State  or  local  authorities  the  Secretary  of  the  Treasury  may  direct 
vessels  bound  for  said  ports  to  undergo  quarantine  at  said  State  or  local 
station. 

SEC.  7.  That  whenever  it  shall  be  shown  to  the  satisfaction  of  the 
President  that  by  reason  of  the  existence  of  cholera  or  other  infectious 
or  contagious  diseases  in  a  foreign  country  there  is  serious  danger  of  the 
introduction  of  the  same  into  the  United  States,  and  that  notwithstanding 
the  quarantine  defense  this  danger  is  so  increased  by  the  introduction  of 
persons  or  property  from  such  country  that  a  suspension  of  the  right  to 
introduce  the  same  is  demanded  in  the  interest  of  the  public  health,  the 
President  shall  have  power  to  prohibit,  in  whole  or  in  part,  the  introduc- 
tion of  persons  and  property  from  such  countries  or  places  as  he  shall 
designate  and  for  such  period  of  time  as  he  may  deem  necessary. 

SEC.  8.  That  whenever  the  proper  authorities  of  a  State  shall  sur- 
render to  the  United  States  the  use  of  the  buildings  and  disinfecting 
apparatus  at  a  State  quarantine  station,  the  Secretary  of  the  Treasury 
shall  be  authorized  to  receive  them  and  to  pay  a  reasonable  compensa- 
tion to  the  State  for  their  use,  if  in  his  opinion  they  are  necessary  to  the 
United  States. 

SEC.  9.  That  the  act  entitled  "  An  act  to  prevent  the  introduction 
of  infectious  or  contagious  diseases  into  the  United  States,  and  to  es- 
tablish a  national  board  of  health,"  approved  March  3,  1879,  be,  and 
the  same  is  hereby,  repealed.  And  the  Secretary  of  the  Treasury  is 
directed  to  obtain  possession  of  any  property,  furniture,  books,  paper 
or  records  belonging  to  the  United  States  which  are  not  in  the  posses- 
sion of  an  officer  of  the  United  States  under  the  Treasur}^  Department 
which  were  formerly  in  the  use  of  the  National  Board  of  Health  or  any 
officer  or  employe  thereof. 

REVISED    STATUTES. 

SEC.  ^794.  There  shall  be  purchased  or  erected,  under  the  orders 
of  the  President,  suitable  warehouses,  with  wharves  and  inclosures, 
where  merchandise  may  be  unladen  and  deposited,  from  any  vessel 
which  shall  be  subject  to  a  quarantine  or  other  restraint,  pursuant  to 
the  health  laws  of  any  State,  at  such  convenient  places  therein  as  the 
safety  of  the  public  revenue  and  the  observance  of  such  health  laws  may 
require. 


QUARANTINE    LAWS   OF   THE   UNITED    STATES.  539 

SEC.  4795.  Whenever  the  cargo  of  a  vessel  is  unladen  at  some  other 
place  than  the  port  of  entry  or  delivery  under  the  foregoing  provisions, 
all  the  articles  of  such  cargo  shall  be  deposited  at  the  risk  of  the  parties 
concerned  therein,  in  such  public  or  other  warehouses  or  inclosures  as 
the  collector  shall  designate,  there  to  remain  under  the  joint  custody  of 
such  collector  and  of  the  owner,  or  master,  or  other  person  having  charge 
of  such  vessel,  until  the  same  are  entirely  unladen  or  discharged,  and 
until  the  articles  so  deposited  may  be  safely  removed  without  contra- 
vening such  health  laws.  And  when  such  removal  is  allowed,  the  col- 
lector having  charge  of  such  articles  may  grant  permits  to  the  respective 
owners  or  consignees,  their  factors  or  agents,  to  receive  all  merchandise 
which  has  been  entered,  and  the  duties  accruing  upon  which  have  been 
paid,  upon  the  payment  by  them  of  a  reasonable  rate  of  storage ;  which 
shall  be  fixed  by  the  Secretary  of  the  Treasury  for  all  public  warehouses 
and  inclosures. 

SEC.  4796.  The  Secretary  of  the  Treasury  is  authorized,  whenever 
a  conformity  to  such  quarantines  and  health  laws  requires  it,  and  in 
respect  to  vessels  subject  thereto,  to  prolong  the  terms  limited  for  the 
entry  of  the  same,  and  the  report  or  entry  of  their  cargoes,  and  to  vary 
or  dispense  with  any  other  regulations  applicable  to  such  reports  or 
entries.  No  part  of  the  cargo  of  any  vessel  shall,  however,  in  any  case, 
be  taken  out  or  unladen  therefrom,  otherwise  than  is  allowed  by  law,  or 
according  to  the  regulations  hereinafter  established. 

SEC.  4797.  Whenever,  by  the  prevalence  of  any  contagious  or  epi- 
demic disease  in  or  near  the  place  by  law  established  as  the  port  of  entry 
for  any  collection  district,  it  becomes  dangerous  or  inconvenient  for  the 
officers  of  the  revenue  employed  therein  to  continue  the  discharge  of 
their  respective  offices  at  such  port,  the  Secretary  of  the  Treasury,  or, 
in  his  absence,  the  First  Comptroller,  may  direct  the  removal  of  the 
officers  of  the  revenue  from  such  port  to  any  other  more  convenient 
place,  within,  or  as  near  as  may  be  to,  such  collection  district.  And  at 
such  place  such  officers  may  exercise  the  same  powers,  and  shall  be  liable 
to  the  same  duties,  according  to  existing  circumstances,  as  in  the  port  or 
district  established  by  law.  Public  notice  of  any  such  removal  shall  be 
given  as  soon  as  may  be.  [See  Sec.  1776.] 

SEC.  4798.  In  case  of  the  prevalence  of  a  contagious  or  epidemic 
disease  at  the  seat  of  government,  the  President  may  permit  and  direct 
the  removal  of  any  or  all  the  public  offices  to  such  other  place  or  places 
as  he  shall  deem  most  safe  and  convenient  for  conducting  the  public 
business.  [See  Sec.  1776.] 

SEC.  4799.  Whenever,  in  the  opinion  of  the  Chief  Justice,  or,  in 
case  of  his  death  or  inability,  of  the  Senior  Associate  Justice  of  the 


540  TEXT-BOOK   OF   HYGIENE. 

Supreme  Court,  a  contagious  or  epidemic  sicknets  shall  render  it  haz- 
ardous to  hold  the  next  stated  session  of  the  court  at  the  seat  of  govern- 
ment, the  Chief  or  such  Associate  Justice  may  issue  his  order  to  the 
Marshal  of  the  Supreme  Court,  directing  him  to  adjourn  the  next  session 
of  the  court  to  such  other  place  as  such  justice  deems  convenient.  The 
marshal  shall  thereupon  adjourn  the  court,  by  making  publication  thereof 
in  one  or  more  public  papers  printed  at  the  seat  of  government  from  the 
time  he  shall  receive  such  order  until  the  time  by  law  prescribed  for 
commencing  the  session.  The  several  circuit  and  district  judges  shall, 
respectively,  under  the  same  circumstances,  have  the  same  power,  by  the 
same  means,  to  direct  adjournments  of  the  several  circuit  and  district 
courts  to  some  convenient  place  within  their  districts  respectively.  [See 
Sec.  1776.] 

SEC.  4800.  The  judge  of  any  district  court,  within  whose  district 
any  contagious  or  epidemic  disease  shall  at  any  time  prevail,  so  as,  in 
his  opinion,  to  endanger  the  lives  of  persons  confined  in  the  prison  of 
such  district,  in  pursuance  of  any  law  of  the  United  States,  may  direct 
the  marshal  to  cause  the  persons  so  confined  to  be  removed  to  the  next 
adjacent  prison  where  such  disease  does  not  prevail,  there  to  be  confined 
until  they  may  safely  be  removed  back  to  the  place  of  their  first  confine- 
ment. Such  removals  shall  be  at  the  expense  of  the  United  States. 

SEC.  4263.  The  master  of  any  vessel  employed  in  transporting  pas- 
sengers between  the  United  States  and  Europe  is  authorized  to  maintain 
good  discipline  and  such  habits  of  cleanliness  among  the  passengers  as 
will  tend  to  the  preservation  and  promotion  of  health ;  and  to  that  end 
he  shall  cause  such  regulations  as  he  may  adopt  for  this  purpose  to  be 
posted  up,  before  sailing,  on  board  such  vessel,  in  a  place  accessible  to 
such  passengers,  and  shall  keep  the  same  so  posted  up  during  the  voyage. 
Such  master  shall  cause  the  apartments  occupied  by  such  passengers  to 
be  kept  at  all  times  in  a  clean,  healthy  state;  and  the  owners  of  every 
such  vessel  so  employed  are  required  to  construct  the  decks  and  all  parts 
of  the  apartments  so  that  they  can  be  thoroughly  cleansed  ;  and  also  to 
provide  a  safe,  convenient  privy  or  water-closet  for  the  exclusive  use  of 
every  one  hundred  such  passengers.  The  master  shall  also,  when  the 
weather  is  such  that  the  passengers  cannot  be  mustered  on  deck  with 
their  bedding,  and  at  such  other  times  as  he  may  deem  necessary,  cause 
the  deck  occupied  by  such  passengers  to  be  cleansed  with  chloride  of 
lime  or  some  other  equally  efficient  disinfecting  agent.  And  for  each 
neglect  or  violation  of  any  of  the  provisions  of  this  section  the  master 
and  owner  of  any  such  vessel  shall  be  severally  liable  to  the  United 
States  in  a  penalty  of  fifty  dollars,  to  be  recovered  in  any  circuit  or 
district  court  within  the  jurisdiction  of  which  such  vessel  may  arrive 


QUARANTINE   LAWS   OF   THE   UNITED    STATES.  541 

or  from  which  she  is  about  to  depart,  or  at  any  place  where  the  owner  or 
master  may  be  found. 

[Extract  from  Act  of  August  1,  1888.] 

Whenever  any  .person  shall  trespass  upon  the  grounds  belonging  to 
any  quarantine  reservation,  .  .  .  such  person,  trespassing,  . 
shall,  upon  conviction  thereof,  pay  a  fine  of  not  more  than  three  hundred 
dollars,  or  be  sentenced  to  imprisonment  for  a  period  of  not  more  than 
thirty  days,  or  shall  be  punished  by  both  fine  and  imprisonment,  at  the 
discretion  of  the  court.  And  it  shall  be  the  duty  of  the  United  States 
Attorney,  in  the  district  where  the  misdemeanor  shall  have  been  com- 
mitted, to  take  immediate  cognizance  of  the  offense,  upon  report  made  to 
him  by  any  medical  officer  of  the  Marine-Hospital  Service,  or  by  any 
officer  of  the  Customs  Service,  or  by  any  State  officer  acting  under 
authority  of  Section  5  of  said  act. 

[Act  of  March  27,  1890.] 

AN  ACT  to  prevent  the  introduction  of  contagious  diseases  from  one  State  to  another 
and  for  the  punishment  of  certain  offenses. 

Be  it  enacted  by  the  Senate  and  House  of  Representatives  of  the 
United  States  of  America  in  Congress  assembled,  That  whenever  it  shall 
be  made  to  appear  to  the  satisfaction  of  the  President  that  cholera, 
yellow  fever,  small-pox,  or  plague  exists  in  any  State  or  Territory,  or  in 
the  District  of  Columbia,  and  that  there  is  danger  of  the  spread  of  such 
disease  into  other  States,  Territories,  or  the  District  of  Columbia,  he  is 
hereby  authorized  to  cause  the  Secretary  of  the  Treasury  to  promulgate 
such  rules  and  regulations  as  in  his  judgment  may  be  necessary  to  pre- 
vent the  spread  of  such  disease  from  one  State  or  Territory  into 
another,  or  from  any  State  or  Territory  into  the  District  of  Columbia,  or 
from  the  District  of  Columbia  into  any  State  or  Territory,  and  to  employ 
such  inspectors  and  other  persons  as  may  be  necessary  to  execute  such 
regulations  to  prevent  the  spread  of  such  disease.  The  said  rules  and 
regulations  shall  be  prepared  by  the  Supervising  Surgeon-General  of 
the  Marine-Hospital  Service,  under  the  direction  of  the  Secretary  of  the 
Treasury.  And  any  person  who  shall  willfully  violate  any  rule  or  regu- 
lation so  made  and  promulgated  shall  be  deemed  guilty  of  a  misde- 
meanor, and  upon  conviction  shall  be  punished  by  a  fine  of  not  more 
than  five  hundred  dollars,  or  imprisonment  for  not  more  than  two 
years,  or  both,  in  the  discretion  of  the  court. 

SEC.  2.  That  any  officer,  or  person  acting  as  an  officer,  or  agent  of 
the  United  States  at  any  quarantine  station,  or  other  person  employed 
to  aid  in  preventing  the  spread  of  such  disease,  who  shall  willfully 
violate  any  of  the  quarantine  laws  of  the  United  States,  or  any  of  the 


542  TEXT-BOOK   OF   HYGIENE. 

rules  and  regulations  made  and  promulgated  by  the  Secretary  of  the 
Treasury  as  provided  for  in  Section  1  of  this  act,  or  any  lawful  order  of 
his  superior  officer  or  officers,  shall  be  deemed  guilty  of  a  misdemeanor, 
and  upon  conviction  shall  be  punished  by  a  fine  of  not  more  than  three 
hundred  dollars,  or  imprisonment  for  not  more  than  one  year,  or  both,  in 
the  discretion  of  the  court. 

SEC.  3.  That  when  any  common  carrier  or  officer,  agent,  or  employe* 
of  any  common  carrier  shall  willfully  violate  any  of  the  quarantine  laws 
of  the  United  States,  or  the  rules  and  regulations  made  and  promul- 
gated as  provided  for  in  Section  1  of  this  act,  such  common  carrier, 
officer,  agent,  or  employe  shall  be  deemed  guilty  of  a  misdemeanor,  and 
shall,  on  conviction,  be  punished  by  a  fine  of.  not  more  than  five  hun- 
dred dollars,  or  imprisonment  for  not  more  than  two  years,  or  both,  in 
the  discretion  of  the  court. 


QUESTIONS   TO   CHAPTER  XXIII. 

QUARANTINE. 

What  is  meant  by  quarantine?  From  what  is  the  term  derived? 
Has  it  now  any  definite  limitation  as  to  time?  To  what  is  the  term 
applied  ?  What  are  the  two  natural  divisions  of  quarantine  ?  What  are 
the  principal  quarantinable  diseases  ?  What  determines  the  length  of 
quarantine  for  each  of  these?  Should  tuberculosis  be  quarantinable? 

What  is  meant  by  foreign  quarantine?  What  regulations  are  now 
to  be  observed  at  foreign  ports  by  vessels  clearing  for  the  United  States? 
What  officers  have  charge  of  this  foreign  quarantine? 

What  are  some  of  the  points  considered  in  the  bill  of  health? 
What  are  some  of  the  requirements  with  regard  to  vessels  and  their 
cargoes  ?  Regarding  passengers  and  crew  ?  What  are  the  objects  of  the 
inspection  card  given  to  passengers  ? 

What  requirements  are  to  be  observed  at  sea?  What  method  is 
prescribed  for  the  disinfection  of  vessels?  Of  cargoes?  What  can  be 
said  of  the  efficiency  of  the  foregoing  regulations  ? 

What  is  meant  by  domestic  quarantine?  What  will  govern  the 
equipment  of  a  maritime  quarantine  station?  What  are  required  at  a 
fully-equipped  station  ?  What  is  the  method  of  construction  of  the  most 
recent  steam  disinfecting  chambers,  and  in  what  ways  are  they  superior 
to  the  earlier  models  ?  What  precautions  are  to  be  observed  in  operating 
them  ?  What  is  the  principle  of  construction  of  the  sulphur-furnaces 
now  used  at  quarantine  stations,  and  wherein  are  they  superior  to  other 
methods  of  producing  sulphurous-acid  gas?  How  is  the  gas  to  be  con- 
veyed into  the  holds  of  vessels,  etc.  ?  What  apparatus  is  provided  for 
using  germicidal  solutions?  Where  barracks  are  necessary,  how  should 
they  be  arranged  and  equipped  ?  What  facilities  for  bathing  should  be 
provided  ?  What  is  to  be  said  of  the  water-supply  ? 

What  regulations  are  to  be  observed  at  ports  of  entry  and  on  the 
frontier  ?  What  points  are  covered  by  the  inspection,  and  what  vessels 
are  exempt  from  inspection?  What  vessels  are  to  be  quarantined,  and 
for  how  long?  What  are  the  general  requirements  at  quarantine?  What 
treatment  must  cholera-infected  vessels  undergo  in  quarantine?  What  is 
the  prescribed  method  of  disinfection  ?  What  routine  is  to  be  observed 
with  passengers  detained  on  account  of  cholera  ? 

(543) 


544  QUESTIONS   TO   CHAPTER    XXIII. 

How  are  the  personal  effects  of  passengers  and  crew  and  the  cargo 
to  be  disinfected  ?  Under  what  conditions  may  traffic  be  allowed  from 
ports  infected  with  yellow  fever?  What  inspection  is  required  of  State 
and  local  quarantines?  What  regulations  govern  the  Canadian  and 
Mexican  frontiers  ?  What  are  some  of  the  points  to  be  observed  in  the 
successful  management  of  a  quarantine  station  ?  • 

What  are  some  of  the  special  points  in  the  disinfection  of  wooden 
vessels  for  yellow  fever  ?  Is  there  any  evidence  that  ballast  may  convey 
infection  ?  What  is  meant  by  "  dipped  ballast"?  How  are  the  holds  of 
wooden  vessels  to  be  disinfected?  What  other  treatment  of  yellow-fever 
vessels  may  be  suggested  ? 

What  is  the  treatment  required  for  cholera-infected  vessels  ?  What 
special  measures  are  to  be  taken  against  cholera?  Who  has  supreme 
command  of  a  cholera  camp,  and  how  is  it  to  be  divided?  What  are  the 
regulations  to  be  observed  in  the  detention  camp?  In  the  hospital 
camp  ?  Why  should  infected  dejecta  and  ejecta  be  disinfected  immedi- 
ately upon  discharge? 

How  many  national  quarantine  stations  are  there,  and  where  are  they 
located?  Give  a  brief  description  of  those  in  the  Delaware  Bay  and 
River.  What  government  vessel  is  used  as  a  quarantine  station  ? 

What  are  some  of  the  aids  to  national  quarantine  ?  What  inspection 
is  required  of  all  quarantines  ?  What  is  required  of  all  State  and  local 
quarantines  ?  What  are  the  instructions,  both  general  and  special,  to  the 
officers  detailed  to  inspect  State  and  local  quarantines? 

What  is  meant  by  inland  quarantine?  By  the  sanitary  cordon? 
When  and  where  has  the  latter  been  employed  in  the  United  States,  and 
with  what  success  ?  What  is  a  camp  of  probation  ?  What  is  the  differ- 
ence between  it  and  a  camp  of  refuge  ?  How  should  a  camp  of  probation 
be  equipped,  managed,  and  guarded  ?  What  should  be  the  daily  routine 
of  such  a  camp  ?  What  regulations  should  be  promulgated  and  enforced 
for  such  a  camp  ?  Have  these  camps  been  efficacious  in  preventing  the 
spread  of  disease  ? 

What  is  the  purpose  of  railroad  quarantine,  and  how  is  it  to  be 
carried  out?  How  may  it  be  facilitated  by  train-inspection  service? 
What  rules  are  to  be  adopted  for  railway  quarantine  ?  What  action  has 
been  taken  to  prevent  the  introduction  of  small-pox,  etc.,  from  Canada? 
What  are  the  regulations  issued  for  the  guidance  of  sanitary  inspectors? 
What  provisions  are  there  for  the  medical  inspection  of  immigrants  on 
board  trains? 

What  general  principles  govern  interstate  quarantine?  What  are 
the  regulations  covering  it  ?  Which  of  these  is  the  most  important  ? 


QUESTIONS   TO   CHAPTER   XXIII.  545 

What  special  provisions  are  made  respecting  yellow  fever?  What  are 
the  methods  of  disinfection  prescribed,  respectively,  for  cholera,  yellow 
fever,  small-pox,  and  typhus  fever? 

What  are  the  essential  points  of  municipal  quarantine?  What  pre- 
cautions are  to  be  taken  to  prevent  the  spread  of  small-pox,  measles, 
diphtheria,  and  scarlet  fever  ?  To  what  extent  should  domiciliary  quar- 
antine be  carried  ?  How  long  should  it  be  maintained  ? 

How  may  a  diagnosis  of  diphtheria  be  made?  What  means  may  be 
taken  to  prevent  the  spread  of  tuberculosis? 

Give  a  synopsis  of  the  quarantine  laws  of  the  United  States.  What 
is  the  maximum  penalty  for  attempting  to  enter  a  port  in  evasion  of 
them?  What  information  of  value  to  quarantine  officers,  etc.,  is 
furnished  weekly?  When  and  by  whom  may  travel  and  traffic  from 
infected  ports  and  places  be  prohibited?  Who  has  supreme  charge  of  the 
enforcement  of  the  quarantine  regulations  ?  In  what  department  of  the 
government  does  the  supervision  of  quarantine  belong  ? 

35 


INDEX. 


Absolute  and  relative  humidity,  6 
Actinoinycosis,  376 
Adjustable  school-desk,  211 
Adulterations  in  milk,  97 

of  flour,  113 

"A.  G.  M."  water-closet,  184 
Aids  to  quarantine,  497 
Air,  1 

currents    and    their    influence    upon 
health,  18 

examination  of,  413 

tests  for  impurities  in,  415 
Alcohol  poisoning,  118 
Alcoholic  beverages,  117 
Alimentary  beverages,  117 
Alkaloidal  beverages,  123 
Alum,  as  a  purifier  of  muddy  water,  63 

in  bread,  437 
Ammonia  in  water,  78 

test  for,  427 

Angus  Smith's  experiments  on  carbon 
dioxide  and  organic  matter,  27 

modification  of,  419 
Aniline  poisoning,  236 
Animal  diseases  and  ground-water,  142 
Annatto  in  milk,  test  for,  433 
Anthrax,  378 

Antiseptics  and  antisepsis,  387 
Arsenie,  in  wall-papers,  177 

poisoning,  241 
Ash  in  flour,  436 

in  milk,  test  for,  433 
Asiatic  cholera,  347 

Atmosphere,  composition  and  physical 
conditions  of,  2 

its  influence  upon  health,  1 

its  limit  upward,  3 
Atmospheric  pressure  and  health,  8 

Bacillus  anthracis  as  a  cause  of  diseased 

meat,  109 
Bacillus  of  anthrax,  378 

of  glanders,  378 

of  typhoid  fever,  57,  67,  362 

tuberculosis,  532 
Bacteria  in  the  atmosphere,  32 
Bacteriological  examination  of  drinking- 
water,  81,  430 

Baker,  H.  B.,  on  effects  of  low  tempera- 
ture on  health,  15 
Barometric  pressure,  3 
Barracks,  252,  464 
Bathing,  dangers  of  cold,  296 

rules  for,  295 


Baths,  and  bathing,  293,  465 

public,  299 
Beer,  122 

Berlier's  system,  156 
Bert's  observations  on  diminished  at- 
mospheric pressure,  10 
Beverages,  alimentary,  117 

alkaloidal,  123 

containing  alcohol,  117 
Birth  rate,  406 
Births,  registration  of,  404 
Black  death,  326 

hole  of  Calcutta,  28 
Boccaccio  on  the  plague,  326 
Bora,  19 

Boric  acid  in  milk,  tests  for,  434 
Boudin  on  malarial  fever  from  drinking- 
water,  64 

Bovine  tuberculosis,  377 
Bowditch,  H.  L,  on  soil  moisture  and 

consumption,  141 
Brandy,  120 

"Brass-founders'  ague,"  235 
Bread,  112 

component  parts  of,  436 
Broad  Street  pump  epidemic  of  cholera, 

68 

Bromine  poisoning,  232 
Buchanan,  Dr.  G.,  on  earth-closets,  154 

on  soil  moisture  and  consumption,  142 
Building  material,  172 
Burial-grounds,   supposed    dangers    of, 

308 

Bury  ventilator,  175 
Butter,  101 

as  food,  434 

component  parts  of,  434 

Cabiadis  on  the  plague  in  Bagdad,  329 
Cable,  G.  W.,  on  convict-lease  system, 

281 

Caisson  disease,  12 
Camp,  detention,  492 

diseases,  254 

hospital,  493 

Perry,  506 

Waynesville  detention,  509 
Camps,  civilian,  258 

of  probation,  505 
Carbon-bisulphide  poisoning,  231 
Carbon  dioxide  in  atmosphere,  2,  26 

poisoning,  230 
Carbon  monoxide,  in  air,  29 

poisoning,  229 

(547) 


548 


INDEX. 


Caterham  epidemic  of  typhoid  fever,  65 
Census,  the,  401 
Cerebro-spiual  meningitis,  372 
Chamber-land's  filter,  73 
Chambers,  J.  W.,   on  pollution  of  hy- 
drant-water, 70 

Chantemesse  and  Vidal  on  the  bacillus 
typhoideus  in  drinking-water, 
67 

Cheese,  102 

Chemical  composition  of  ground-air,  133 
Chlorides  in  water,  76 
Chlorine-gas  poisoning,  228 
Chlorine  in  water,  tests  for,  424 
Chocolate,  124 
"Choke-damp,"  230 
Cholera,  14,  68 

and  drinking-water,  354 

and  ground-water,  140 

Asiatica,  347,  520,  524 

bacillus,  352 

camp,  regulations  for,  491 

causation  of,  353 

from  infected  water,  68 

prevention  of,  356 

special  quarantine  measures  against. 
488 

vessels,  treatment  of,  486 
Cider,  121 

Cisterns  as  storage  reservoirs,  51 
Civilian  camps,  258 
Classification  of  drinking-waters,  82 
Clothing,  absorption  of  heat  by,  301 

how  to  render  non-inflammable,  304 

materials,  301 

of  the  soldier,  251 
Coal-gas,  30 
Coffee,  123 
Condiments,  114 
Connolly  trap,  190 

Consumption,  among  school-children, 
218 

and  soil  moisture,  141 

prevention  of,  533 
Contagion  and  infection,  319 
Contagious  diseases  and  schools,  218 
Contagium  animatum,  313 
Contamination  of  hydrant-water,  70 
Cooking,  methods  of,  115 
Cowles,  Dr.  E.,  experiments  on  heating 

hospitals,  200 
Creamometer,  100 
Cremation,  162,  310 

of  sewage  and  garbage,  162 
Crematory  at  quarantine  stations,  465 
Cucumber  odor  in  drinking-water,  56 
Cultivation  of  bacteria,  316 
Cultures  in  suspected  diphtheria,  532 
Cysticercus  in  meat,  106 

Da  Costa,  Dr.  J.  M.,  on  irritable  heart, 
288 


Daily  allowance  of  water  in  American 

cities,  50 

Dead,  disposal  of,  307 
Death-rate  and  birth-rate  406 
Deaths,  registration  of,  405 
Decayed  meat  and  fish  as  causes  of  dis- 
ease, 106 

"Dececo"  closet,  185 
DeChaumont's  rule  regarding  ground- 
water  oscillations,  140 
Defective   hearing   among    school-chil- 
dren, 216 

Defoe  on  the  plague,  327 
Delabarre,  F.  A.,  on  physical  develop- 
ment, 288 
Dengue,  369 
Deodorizers,  388 

Diarrhoea  and  dysentery  in  armies,  254 
Diarrhoeal  diseases,  14 
Dickson  on  the  plague  in  India,  329 
Digestive  derangements  among  school- 
children, 217 
Diphtheria,  322,  368,  529 

diagnosis  of,  531 

Diseases  caused  by  high  temperature, 
14 

from  impure  water,  62 

from  infected  and  spoiled  meat,  105 

from  infected  milk,  98 

from  soil  impurities,  139 

of  animals  communicable  to  man,  376 

of  school-children,  213 

on  shipboard,  271 

registration  of,  405 
Disinfectants  and  disinfection,  387 
Disinfection,  methods  of,  393 

by  germicidal  solutions,  463 

for  cholera,  524 

for  small -pox,  525 

for  typhus  fever,  526 

for  yellow  fever,  525 

of  wooden  vessels,  479 
Distilled  water,  58 
Domestic  quarantine,  458 
Domiciliary  quarantine,  527 
Drainage  of  wet  soils,  143 
Drinking-water,  examination  of,  81 

sources  of,  51 

standards  of  purity  of,  59 
Drowned  persons,  restoration  of,  296 
Duration  of  infection,  321 
Dwellings,  and  overcrowding,  165 

heating  and  ventilation  of,  174 

materials  of  which  to  be  built,  172 
Dysentery,  14 

Earth-closets,  153 

Eberth's  bacillus  as  a  cause  of  typhoid 

fever,  67 

Eggs  as  food,  111 
Elephantiasis,  14 
Electric  light  and  its  dangers,  179 


INDEX. 


549 


Emigrant  ships,  sanitary  and  medical 

service  on  board,  273 
Emmerich  on  the  innocuousness  of  im- 
pure water,  65 
Entombment,  309 
Epidemic  diseases,  320,  372 

due  to  defective  ventilation,  29* 

history  of,  325 

Erismann  on  Liernur's  system,  155 
Examination  of  air,  water,  and  food,  413 
Exercise  and  training,  285 

physiological  effects  of,  285 

Fats  in  milk,  test  for,  433 
Fever,  malarial,  14,  63,  64,  255 

mountain,  53 

relapsing,  360 

scarlet,  99,  322,  367,  529 

splenic,  314 

typhoid,  65,  67,  141,  256,  322,  361,  409 

typhus,  256,  363,  526 

yellow,  14,  135,  364,  485,  503,  509,  512, 

523,  525 

Filtration  of  water,  73 
"Fire-clamp,"  30,  230 
Flour  and  bread,  436 

component  parts  of,  436 

tests  for  impurities  in,  437 
Flushing  cistern  for  water-closets,  187 
Fodor  on  the  production  of  carbon  di- 
oxide, 27 
Fohn,  19 
Folsom,  C.  F.,  "on  typhoid  fever  from 

infected  water,  67 
Food,  examination  of,  431 

necessary  to  health,  87 

of  the  soldier,  250 
Foods,  classification,  of,  95 

cooking  of,  115 

of  animal  origin,  95 

of  vegetable  origin,  112 
Foreign  quarantine,  443 
Forwood,  Dr.  W.  S.,  on  hydrochloric- 
acid  fumes,  228 

Freire  on  yellow-fever  genii  in  soil,  135 
Fresh-air  inlet,  191 
Fruits  and  nuts,  114 

Gardner,   James  T.,  on  Rochdale  sys- 
tem, 151 

Gas  poisoning,  29 
Germ  theory,  313 

Germicidal  solutions,  disinfection  by,  463 
Gihon,  Dr.  A.  L.,  on  naval  hygiene,  261 

on  syphilis  in  the  United  States,  342 
Gin,  121 
Glanders,  378 
Green  vegetables,  114 
Ground-air,  132 
Ground-water,  137 

and  cholera,  140 

and  typhoid  fever,  141 


Habitations,  165 
Habits  of  the  sailor,  261 
Haemic  diseases,  14 

Hammond's  experiment  on  organic  mat- 
ter in  the  air,  28 
Hardness  of  water,  60 

tests  for,  428 
Harmattan,  19 

Heart  disease  and  altitude,  11 
Heating  and  ventilation  of  dwellings, 

174 

Hecker  on  the  plague,  326 
Hold,  ship's,  disinfection  of,  483 
Hopper-closets,  182 

Hospital,   administration  and  manage- 
ment, 203 

records,  205 
Hospitals,  construction  of,  195,  463 

management  of,  203 

ventilation  and  heating  of,  199 
House,  building  material  of,  172 

interior  arrangements  of,  174 

sanitary  arrangements,  supervision  of, 
191 

water-supply  of,  180 
House-drainage,  180 
Howard,  John,  on  hospital  construction, 

199 
Humidity,  and  health,  18 

of  the  atmosphere,  5 
Hydrophobia,  377 
Hygiene,  industrial,  223 

marine,  261 

military  and  camp,  249 

prison,  279 

school,  207 

Illuminating  gas,  dangers  of,  178 
Impurities  in  water,  59 

signification  of,  80 

tests  for,  74 

Increased  atmospheric  pressure,  12 
Incubation  of  infectious  diseases,  table 
of,  321 

report    of,    to    the    London    Clinical 

Society,  321 
Industrial  hygiene,  223 
Infants,  mortality  among,  408 
Influence  of  barometric  pressure  upon 

results  of  operations,  12 
Influenza,  15,  322,  371 
Ingrafting,  335 
Inland  quarantine,  501 
Inoculation  of  small-pox,  335 
Interment,  307 

in  war,  310 
Interstate  quarantine,  521 

regulations  governing,  522 
Iodine  poisoning,  232 

Jenner,  Edward,  and  vaccination,  338 
Jesty,  Benjamin,  338 


550 


INDEX. 


Johns  Hopkins  Hospital,  196 
Jones,  Dr.  Joseph,  on  syphilis  among 
the  mound-builders,  374 

Kefyr,  122 

Kober,  G.  M.,  on  mountain  fever,  53 

Koch,  R.,  on  the  cholera  spirillum  in 

drinking-water,  69 
Kumys,  122 

Lactometer,  100 

Lactoscope,  100 

Lakes  and  ponds  as  sources  of  drinking- 
water,  55 

Lambrecht's  poly  meter,  8 

Latrines,  465 

Lead  poisoning,  233 

Legumes,  113 

Liernur's  pneumatic  system,  155 

Lighting  of  dwellings,  177 

Lortet's  observations  on  diminished  at- 
mospheric pressure,  8 

Low  temperature  as  a  cause  of  respira- 
tory diseases,  15 

Malarial  fevers,  14 

in  armies,  255 
Marine  hygiene,  261 
Maritime  quarantine,  458 

administration  of,  466 
Marriages,  registration  of,  404 
Marsh-water  and  malaria,  63 
Marshall,  John,  on  cholera  from  infected 

water,  68 
Mate",  125 

McClellan's  trap,  188 
McSherry,  R.,  on  siguatera,  108 
Measles,  322,  367,  529 
Meat,  103 

extracts  and  essences,  105 
Mercurial  poisoning,  234 
Metabolism  during  muscular  exercise, 

94 
Methods  of  cooking,  115 

of  sewage  removal,  148 
Michigan   method  of  restoring  the  ap- 
parently drowned,  297 
Midden  privies,  150 
Military  and  camp  hygiene,  249 
Milk,  as  food,  95,  431 

adulteration  of,  432 

component  parts  of,  432 

sickness,  100 

tyrotoxicon  in,  101 
Mineral  poisons  in  water,  79 

tests  for,  429 
Mistral,  18 
Montagu,  Lady  M.  W.,  on  inoculation, 

335 

Montgomery  quarantine  conference,  515 
Moore,  J.  W.,  on  seasonal  prevalence 
of  pneumonia,  17 


Morin,  on  fresh  air  required  in  occupied 

apartments,  40 
Mortality  among  infants,  408 

in  prisons,  281 

Motion  of  the  atmosphere,  7 
Mountain  fever,  53 

sickness,  10 

Municipal  quarantine,  526 
Mumps,  322 
Myopia  of  school-children,  213 

National  quarantines,  494 
aids  to,  497 

stations,  regulations  for,  466 
Naval  hygiene,  261 

rations,  268 
Neirnsee,  J.  R.,  on  ventilating  hospital 

wards,  200 

Nervous  disorders   among  school -chil- 
dren, 217 

Nichols,  A.  H.,  on  pollution  of  drinking- 
water,  56 
Nitrates  and  nitrites  in  water,  77 

tests  for,  425,  426 
Norther,  19 

Occupation  neuroses,  245 
Occupations,  hygiene  of,  223 
Oleo-margariue,  102,  434 
Organic  matter  in  water,  75 
Organisms  in  small-pox,  334 
Oriental  plague,  325 
Over    Darwen    epidemic    of   drinking- 
water,  66 
Overexertion,  288 

Oxygen  and  CO2  in  ground-air,  134 
Oxygen  in  atmospheric  air,  3 
Ozone  in  the  atmosphere,  7 

Pan- closets,  181 

Passengers  on  shipboard,  264 
protection  of,  273 

report  on,  to  American  Public  Health 
Association,  274 

Pathogenic  organisms  in  ground-air,  134 

Pavilion  hospitals,  18 

Pebrine,  314 

Pengra,  C.  P.,  on  bacteria  in  drinking- 
water,  57 

Pepper,  William,  on  consumption  and 
soil  moisture,  142 

Perlsucht,  377 

Peroxide   of   hydrogen    in   the   atmos- 
phere, 7 

Petroleum  vapor  as  a  poison,  233 

Pettenkofer,  on  carbon  dioxide  in  air, 

420 

on  ground-air,  133 
on  ground-water  and  cholera,  355 

Phosphates  in  water,  tests  for,  430 

Phosphorus  necrosis,  242 

Phthisis  in  armies,  256 


INDEX. 


551 


Physical  development,  table  on,  289 

training,  286 

Physiological  action  of  alcohol,  117 
Plague,  325 
Plunger-closets,  182 
Plymouth  epidemic  of  typhoid  fever,  67 
Pneumonia  and  cold  weather,  16 
Poisonous  dust,  237 

gases  and  vapors,  227 
Power,  W.   H.,  on  scarlet  fever  from 

milk,  99 

Preventive  inoculation,  315 
Prison  hygiene,  279 

punishments,  282 

Privies,    deodorization  of  contents   of, 
149 

removal  of  contents  of,  149 

ventilation  of,  149 
Privy-vaults,  construction  of,  148 

pits,  150 

system,  148 

wells,  150 

Procopius  on  the  plague,  325 
Prudden  on  typhoid  bacilli  in  drinking- 
water,  57 

Ptomaines  in  meat,  107 
Public  baths,  299 
Purification  of  drinking-water,  72 
Purulent  conjunctivitis,  256 

Quarantinable  diseases,  442 
Quarantine,  441 
aids,  497 

conference  at  Montgomery,  515 
contrivances,  459 
danger  from  flies  in,  494 
domestic  458 
domiciliary,  527 
foreign,  443 

regulations,  efficiency  of,  456 
inland,  501 
interstate,  521 
laws  of  United  States,  534 
municipal,  526  , 
plant,  459 
railroad,  512 
regulations  governing,  466 

to  be  observed  at  foreign  ports  and 

at  sea,  443 

service,  national,  494 
stations,  management  of,  477 

maritime,  458 

on  Delaware  Bay  and  River,  495 
Quarantines,  national  inspection  of  all, 

498 

instructions  for  inspecting  officers,  499 
Questions  to  chapter  i,  45-48 
to  chapter  ii,  84-86 
to  chapter  iii,  126-129 
to  chapter  iv,  145,  146 
to  chapter  v,  163,  164 
to  chapter  vi,  193,  194 


Questions  to  chapter  vii,  206 
to  chapter  viii,  220,  221 
to  chapter  ix,  247,  248 
to  chapter  x,  260 
to  chapter  xi,  278 
to  chapter  xii,  284 
to  chapter  xiii,  291 
to  chapter  xiv,  300 
to  chapter  xv,  305 
to  chapter  xvi,  312 
to  chapter  xvii,  317 
to  chapter  xviii,  323 
to  chapter  xix,  380-385 
to  chapter  xx,  399,  400 
to  chapter  xxi,  411,  412 
to  chapter  xxii,  439,  440 
to  chapter  xxiii,  543-545 

Rabies,  377 

Rag-sorters'  disease,  240 

Railroad  inspection  against  small -pox, 

516 

against  yellow  fever,  514 
medical     inspection    of    immigrants 

against  cholera,  520 
quarantine,  512 
Rain-water,  52 
Registration  of  births,  404 
of  deaths,  405 
of  diseases,  405 
of  marriages,  404 
Relapsing  fever,  360 
Rennie  on  the  plague,  329 
Restoration  of  apparently  drowned  per- 
sons, 296 
River-water,  52 
Rochdale  system,  151 
Roy,  A.,  on  carbon -dioxide  poisoning, 

230 

Rubeola,  322 
Rum,  121 

Sailor-life,  261 
Sanitary  cordon,  501 
Sausage  poisoning,  107 
Scarlet  fever,  322,  367,  529 

from  milk,  99 

Schlagintweit's  observations  on  mount- 
ain sickness,  9 
Schone  system,  156 
School-furniture,  210 

-house  construction,  207 

-hy*giene,  207 

-life,  diseases  of,  213 
Scurvy  in  armies,  256 
Sea-bathing,  294 

Season  and  mortality  from  various  dis- 
eases, 20 
Seaton   and    Buchanan    on    protective 

power  of  vaccination,  341 
Self- purification  of  flowing  water,  54 
Separate  system,  156 


552 


INDEX. 


Sewage,  and  sewerage,  147 

farms,  161 

final  disposal  of,  161 

irrigation  at  Pullman,  161 

removal,  methods  of,  148 
Sewer- air,  30 
Sheep  pock,  376 
Ship  sanitation,  264 
Siegfried,  Surg.  C.  A.,  on  naval  rations, 

271 

Simoon,  19 
Sirocco,  19 

Site  for  dwellings,  167 
Small-pox,  331,  516,  525 

limiting  the  spread  of,  conference  in 

Chicago,  346 
Smart,  C.,  on  mountain  fever,  53 

on  pollution  of  cistern-water,  51 
Soap  test  for  hardness  in  water,  60 
Soil,  atmosphere  of,  132 

character  of,  for  building  sites,  168 

drainage,  143 

its  physical  and  chemical  characters, 
131 

moisture  and  health,  167 

pipe,  189 

water  of  the,  137 
Solids  in  water,  75 

of  milk,  tests  for,  433 
Sources  of  drinking-water,  51 
Spinal  curvature  in  school-children,  217 
Spirillum  of  relapsing  fever,  361 
Splenic  fever,  314 
Spongilla  fluviatilis,  56 
Spring-water,  57 
Standards  of  purity  of  drinking-water, 

59 

Statistics,  vital,  401 
Steam  disinfecting  chambers,  460 
Sternberg,    Gr.    M.,    on    destruction    of 
pathogenic    germs    by  boiling 
water,  72 

on  yellow-fever  germs  of  Freire,  135, 

365 

Storage  of  water,  51,  71 
Study-hours  for  pupils,  212 
Suicide  and  season,  26 
Sulphur-furnace,  462 
Sun-stroke  and  humidity,  13 
Supervision  of  sanitary  arrangements, 

191 

Sweating  sickness,  330 
Swell-head,  376 
Swill-milk,  99 
Syphilis,  373 

Table  of  constituents  of  animal  foods, 
90 

of  constituents  of  vegetable  foods,  91 
Tea,  124 
Temperature  and  health,  13 

of  the  air,  5 


Temperature  of  fire -rooms  of  ships,  268 
Tents  and  huts,  253 

Tests   for  atmospheric    impurities,    33, 
415 

•for  impurities  in  drinking-water,  74, 

423 

in  food,  431 
Texan  northers,  19 

Thome  on  typhoid  fever  from  drinking- 
water,  65 
Tobacco,  125 

Toilet's  system  of  barracks,  252 
Tracy,    Dr.    R.    S.,    on    infecundity  of 

tobacco-workers,  239 
Training,  physical,  286 
Traps,  187 
Trembles,  the,  100 
Trichina  spiralis  in  meat,  105 
Tuberculosis,  532 
Tuberculous  meat,  110 
Turpentine  vapor,  effects  of,  232 
Typhoid  fever,  361,  322 

and  ground-water,  141 

causation  of,  362 

from  drinking-water,  65 

in  armies,  256 
Typhus  fever,  363 

in  armies,  256 
Tyrotoxicon  in  milk,  101 

Vaccination,  337 

and  syphilis,  343 

mode   of    performing  the   operation, 

341 

Valve-closets,  182 

Vaughan,    V.    C.,    on  the  bacillus   ty- 
phoideus  in  drinking-water,  68 

on  poisonous  cheese,  103 

on  tyrotoxicon  as  a  cause  of  cholera 

infantum,  101 
Vaughan's  daily  ration,  89 
Vegetables,  green,  114 
Venereal  diseases  in  armies,  257 
Ventilation,  38  « 

and  heating  of  hospitals,  199 

of  prisons,  282 

of  ships,  266 
Vessels,  cholera,  treatment  of,  486 

wooden,  disinfection  of,  479 

yellow-fever,  treatment  of,  485 
Vital  statistics,  401 
Voit's  standard  diet-tables,  89 

Warms;  system  at  Memphis,  157 

examination  of,  423 
Water,  49 

hardness,  of,  60 
tests  for,  428 

impurities  in,  59 

diseases  due  to,  62 

required  by  human  beings,  49 

storage  and  purification  of,  71 


INDEX. 


553 


Water-supply,  at  quarantine  stations,  465 

in  dwellings,  180 

tests  for  impurities  in,  74,  423 
Water-carriage    system   of  sewage    re- 
moval, 156 
Water-closets,  181 
Well-water,  57 
Whisky,  120 
Wines,  121 
Wolpert's  air-tester,  34 


Wolpert's  air-tester,  modification  of,  418 
Wool-sorters'  disease,  240 
Wy man's  cuse-record,  205 

Yellow  fever,  14,  364 
causation  of,  14,  365 
cordon  in  Texas,  503 
epidemic  in  Brunswick,  Ga.,  509 

in  Florida,  512 
vessels,  treatment  of,  485 


J  >* 

\\   o* 

t  ^>r. 


' 

>  r*- 


§""'••' 
913 


WA100 
R737t 


Rone,  George  H 

Text-book  of  hygiene  . 


WA100 
3737t 


,  George  H 
Text-tc  ,giene   ... 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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